Constituent Privacy Release Form

I hereby authorize Assemblyman Andrew Raia to request on my behalf, pertinent to the Freedom of Information and Privacy Act, access to information concerning me in the files of:

Assemblyman Raia is also authorized to see any materials that may be disclosed to that request, and to speak on my behalf.

Name:

Date of Birth _____/_____/_____

County of Origin:

Current Mailing Address (NO P.O. Boxes):

E-mail:

Telephone Numbers: (Home)_______________________________

(Work)________________________

List any identifying numbers that might apply to your situation:

Immigration "A" Number:_________________________________	Date Filed:_________________
Case Number:
Application Type:
Name of Embassy:
Date of Last Correspondence with Immigration:
Briefly state the nature of your problem (be specific):

I hereby declare that I am currently a resident of the 9th Assembly District and the above information is truthful and complete to the best of my knowledge. In addition, if it is found that the above information is not truthful and complete, my case will be closed and no further action will be taken on my behalf by Assemblyman Andy Raia and/or his staff.

Signature:	Date: _____/_____/_____
District Representative:

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