House of Reps

Office of Representative Kim Schrier

Digital Privacy Release Form

Complete the form below to request help with a Federal Agency. When complete, click Submit to send to our office for assistance.

Fields marked with * are required

Please Provide Applicable Identifying Information

To be able to assist you, we must have a signed privacy release form that clearly outlines your problem and the remedy you are seeking. By checking the box below you are giving our office permission to look into the matter on your behalf. Please make sure to attach below any relevant identifying information and supporting documents which relate to your inquiry.
I hereby request the assistance of the Office of Representative Kim Schrier to resolve the matter described below. I authorize Rep. Kim Schrier to receive any information that they might need to provide this assistance. The information I have provided to Rep. Kim Schrier is true and accurate to the best of my knowledge and belief. The assistance I have requested from Rep. Kim Schrier is in no way an attempt to evade or violate any federal, state, or local law.