INFORMATION AND PRIVACY ACT RELEASE

(Active Duty Military)

SERVICE MEMBER INFORMATION:

FULL NAME:

BRANCH OF SERVICE AND RANK:

SOCIAL SECURITY NUMBER:

CURRENT MILITARY ADDRESS AND UNIT:

OTHER ADDRESS, IF APPLICABLE:

PHONE NUMBER(s):

DATE OF BIRTH:

DATES OF SERVICE:

ASSISTANCE NEEDED:

List members of your chain of command working to resolve the situation, if any:

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AUTHORITY FOR RELEASE OF INFORMATION

I HEREBY AUTHORIZE THE RELEASE OF INFORMATION AND RECORDS TO SENATOR LEAHY'S OFFICE:

SIGNATURE: X____________________________________ DATE: _______________