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Privacy Authorization Form

Name:
First Middle Last
Date of Birth:
Social Security Number:
Street Address:
City:
State:
Zip:
Phone:
Home Work Cell
Email:
Agency Involved:
Agency Case Number(s):
(VA Claim, Alien Number, Tax ID, etc.)
If there is no case number, indicate "None"
Branch of Service: (if applicable)
Military Rank: (if applicable)
Briefly describe the issue you are having:
If you have contacted any other agencies or organizations for assistance with this matter, please list them and the result of each:
List any other individuals associated with your case: (Power of Attorney, Spouse, Child, Attorney, etc)

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