11-25-19 Handout Item 4.AJOHN H. RUTHERFORD
47H DISTRICT. FLORIDA
con:gregti of the Eniteb tate
gouge of Itepregentatibeg
Jatihington, Rie 20515-0904
PRIVACY RELEASE
COMMITTEE ON
APPROPRIATIONS
In accordance with the provisions of The Privacy Act of 1974 (Public Law 93-579), I am required to have your written
permission prior to contacting a federal agency on your behalf. Since emails do not contain a valid signature, they do not
fulfill the requirements of the law.
PLEASE PRINT
Name: Mr, or Ms. / r !! ((e' rn G1 ' S.Se Date of Birth:
Street Address: *O' \C
City W(1 r fk
Phone number:
Social Security Number:
Email:
Apt. #:
State Et.- Zip Code
VA Claim Number:
Other numbers identifying your case: 5 61 - CDOOV G Cp —
Federal agency involved:
Please provide a brief description of the problem and, if necessary, attach additional sheets.
I. the undersigned, hereby authorize the release of all pertinent information to and by Congressman John Rutherford or
any authorized member of his staff to make an inquiry on my behalf
Signature:
1711 LONGWORTH HOUSE OFFICE BUILDING
WASHINGTON, DC 20515
2021225-2501
Date:
PLEASE RETURN COMPLETED FORM TO:
4130 Salisbury Road, Suite 2500
Jacksonville, FL 32216
PRINTED ON RECYCLED PAPER
4130 SALISBURY ROAD
Suns 2500
JACKSONVILLE, FL 32216
904) 831-5205
JOHN H. RUTHERFORD
4TH DISTRICT, FLORIDA
QCongre55 of tfje Einiteb ,tate5
gouge of ikepregentatibeg
liagi)ington, )DC 20515-0904
PRIVACY RELEASE
COMMITTEE ON
APPROPRIATIONS
In accordance with the provisions of The Privacy Act of 1974 (Public Law 93-579), 1 am required to have your written
permission prior to contacting a federal agency on your behalf. Since emails do not contain a valid signature, they do not
fulfill the requirements of the law.
PLEASE PRINT
Name: Mr. DI
Street Address:
City
Phone number:
Social Security Number:
AV)-- Email:
State
Date of Birth: P/1)
Apt. #:
Zip Code
G -14 i CYC
VA Claim Number: V r
Other numbers identifying your case:
Federal agency involved:
Please provide a brief description of the problem and, if necessary, attach additional sheets.
tWiliAeMACCL. Siach fe-SF
COat netitt4-14 uirl-nrovui
4A. vmagi.
Go3' G L 4 ,mss
5Kvt,
I, the undersigned, hereby authorize the release of all pertinent information to and by Congressman John Rutherford or
any authorized member of his staff to make an inquiry on my behalf.
Signature: LL
1711 LONGWORTH HOUSE OFFICE BUILDING
WASHINGTON, DC 20515
202)220-2501
Date: Z D awl
PLEASE RETURN COMPLETED FORM TO:
4130 Salisbury Road, Suite 2500
Jacksonville, FL 32216
PRINTED ON RECYCLED PAPER
4130 SALISBURY ROAD
SunE 2500
JACKLONVILLE, FL 32216
904) 531-5205
JOHN H. RUTHERFORD COMMiTFEE ON
4TH DISTRICT, FLORIDA APPROPRIATIONS
QCongrea of the /Aniteb irotatelS
jf)011ffe of RepregentatibtO
aiihington, DC 20515-0904
PRIVACY RELEASE
In accordance with the provisions of The Privacy Act of 1974 (Public Law 93-579), 1 am required to have your written
permission prior to contacting a federal agency on your behalf. Since emails do not contain a valid signature, they do not
fulfill the requirements of the law.
PLEASE PRINT
Name: Mr. or
Street Address: j\ VY/W e k
City R,0),M10_
Date of Birth: /Z4/(62)
Apt. #:
State P- Zip Code 37%33
Phone number: OA 6X1.52 ?o G7 Email: V) n CNL
Social Security Number:
Other numbers identifying your case:
Federal agency involved:
VA Claim Number:
Please provide a brief description of the problem and, if necessary, attach additional sheets.
1, the undersigned, hereby authorize the release of all pertinent information to and by Congressman John Rutherford or
any authorized me ber •f his staff to make an inquiry on my behalf.
Signature:
1711 LONGWORTH HOUSE OFFICE sib ING
WASHINGTON, DC 20515
2021 225-2501
Date: l i_j
PLEASE REI R1(1 COMPLETED FORM TO:
4130 Salisbury Road, Suite 2500
Jacksonville, FL 32216
PRINTED ON RECYCLED PAPER
4130 SALISBURY ROAD
SUITE 2500
JACK:ONVILLE, FL 32216
9041831-5205
JOHN H. RUTHERFORD COMMITTEE ON
4TH Osumi, FLORIDA APPROPRIATIONS
QCongregs:4 of tfje rtiteb Otatt
gouge of AepreSentotibeo
Jlagfjington, Ott 20515-0904
PRIVACY RELEASE
In accordance with the provisions of The Privacy Act of 1974 (Public Law 93-579), 1 am required to have your written
permission prior to contacting a federal agency on your behalf. Since emails do not contain a valid signature, they do not
fulfill the requirements of the law.
PLEASE PRINT
Name: Mr, Ms, KeS r hrot by -Int Wet --c5 fate of Birth: -11 24 i
Street Address: c5 S C i r a C \2--0aot Apt. #:
City A-VittAt-'L -C .-1/—State Zip Coded Zy
Phone number: 110'i_11 -
Social Security Number:
Email: 6U.&I-ers c (fitb tits
VA Claim Number:
Other numbers identifying your case:
Federal agency involved:
Please provide a brief description of the problem and, if necessary, attach additional sheets.
1, the undersigned, hereby authorize the release of all pertinent information to and by Congressman John Rutherford or
any authorized member of his staff to make an inquiry on my behalf:
Signature: / L
1711 LONGWORTH HOUSE OFFICE BUILDING
WASHINGTON, DC 20515
2021225-2501
Date: _
LEASE RETURN COMPLETED FORM TO:
4130 Salisbury Road, Suite 2500
Jacksonville, FL 32216
PRINTED ON RECYCLED PAPER
2417
4130 SALISBURY ROAD
SUITE 2500
JACKSONVILLE, FL 32216
9041831-5205
JOHN H. RUTHERFORD COMMITTEE ON
4TH DISTRICT, FLORIDA
QCongresz of tfjeMittel) ibtatd
Its ounce of AepregentatibtS
allaftington, AC 20515-0904
PRIVACY RELEASE
APPROPRIATIONS
In accordance with the provisions of The Privacy Act of 1974 (Public Law 93-579), 1 am required to have your written
permission prior to contacting a federal agency on your behalf Since emails do not contain a valid signature, they do not
fulfill the requirements of the law.
PLEASE PRINT
Name: Mr r Ms.
L
i
Street Address: _.,
City 13corl
Phone number: 90--y-a ! 2712 1 - Email:
0000 c26 V A Claim Numbe '
Other numbers identifying your case: GCVO 2 7-
Federal agency involved:
Please provide a brief description of the problem and, if necessary, attach additional sheets.
Apt. #:
r ._
tate F Zip Code 34,23
440/e P<5__IeL) CO
I. the undersigned, hereby authorize the release of all pertinent information to and by Congressman John Rutherfbrd or
any authorized member of his staff to make an inquiry on my behalf.
Signature:
1711 LONGWORTH HOUSE OFFICE 8LJILOING
WASHINGTON, DC 20515
2021225-2501
Date: _----lis/1
PLEASE RETURN COMPLETED FORM TO:
4130 Salisbury Road, Suite 2500
Jacksonville, FL 32216
PRINTED ON RECYCLED PAPER
4130 SALISBURY ROAD
SURE 2500
JACKSONVILLE, FL 32216
904) 831-5205