Before Representative Walden can make inquiries on your behalf, he is required to obtain a signed Privacy Release Form. The information on this form will not be used for any purpose other than official business.
Please fill out the information below - when using this form, you'll fill in the information on each field and when finished, you'll be asked to print out the form (it will not be submitted to Representative Walden's office electronically). After you've printed the form, please be sure to fill out the Social Security number and signature fields before sending this to Congressman Walden's office in either Bend or Medford (when you print the form, you will be told where you should send it).
As required by Public Law 93-579, the Privacy Act, I hereby request and authorize Congressman Walden 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 Representative Walden 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.
* indicates required field.
Date of Birth:
Federal Agency involved:
Veteran's Claime 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. Please be aware that Representative Walden can only act with that person's permission.
On Behalf of Family Member:
If you have contacted another congressional office regarding this issue, please list the office.
Other Office Contacted:
Detailed Description of Problem:*
Please note: By federal law (18 USC, Sec. 205), neither Representative Walden nor his staff can involve themselves in private legal
matters or represent constituents in judicial proceedings.
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