Before Congressman Dent can make inquiries on your behalf, many federal agencies require that you send us a signed copy of the Privacy Act Waiver. Please fill out the information below, then manually fill out the Social Security number and signature fields before mailing or faxing to Congressman Dent's office.

As required by Public Law 93-579, the Privacy Act, I hereby request and authorize Congressman Dent to intercede on my behalf, including the right to review all appropriated documentation that he or his staff deems necessary in connection with the application for assistance or any other action I have pending with the agency named below. I understand that any documents I provide to Congressman Dent or his staff may be copied and forwarded to officials of the agency listed below for review. I understand that all Federal agencies are allowed a minimum of 30 days to respond to congressional inquiries.

Please Note: this form is for printing only; this information will not be tranferred by email or into a database.
Full Name:
E-mail Address:
Address 1:
Address 2:
Zip Code:    
Date of Birth:    
Federal Agency Involved:
Veteran's Claim Number:    
Military Branch of Service:
Alien Registration Number:    
If you are requesting assistance on behalf of a family member, please provide that person's name.
Family Member Name:
If you have contacted another congressional office regarding this issue, please list the office.
Other Office:
Detailed Description of Problem: