In order to respond to his inquiry about me and to give him status reports on my case/claim, I realize that it may be necessary to release information about me which, under the Privacy Act of 1974 (Public Law 93-579), cannot be released without my written consent.

This letter is to serve as my consent for the release to:

Representative Xavier Becerra

Address                                                               

or his designee, information pertaining to my case/claim.

Name                                                                  

Date                                                                    

Address                                                               

SSN                                                                

Signature