STEP 2: FILL OUT PRIVACY RELEASE FORM

Congressman Lee Terry
2nd Congressional District, Nebraska

Please check your information carefully. By clicking on "Next" button, you will be able to PRINT this form. Please sign the form and send to my district office at 11717 Burt Street, Ste. 106, Omaha, NE 68154, or fax to 402.397.8787.

Name:

Full Postal Address:

Home phone:    Business phone:

Please complete blanks where applicable:

Social Security Number: 

Veterans Claim Number:

Military Identification Number:

Other numbers identifying your case:

Types of benefits I am seeking:

Date and Place claim was filed: (mm/dd/yyyy)

Federal agency involved:

Additional information/explanation of request:

In accordance with the provisions of the Privacy Act, I hereby authorize Congressman Lee Terry or a member of his staff to make the appropriate inquiry on my behalf.

( Signature )

Please check your information carefully. By clicking on "Next" button, you will be able to PRINT this form. Please sign the form and send to my district office at 11717 Burt Street, Ste. 106, Omaha, NE 68154, or fax to 402.397.878.