Senator Skoufis's Privacy Release Form

January 28, 2025

Constituent Services

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION FORM

By signing this form, I am hereby authorizing the Office of State Senator James Skoufis to discuss and or receive information, records and documentation regarding my case.

Title

First

Middle

Last

Suffix

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

Agency Name

Agency Case Number / Reference / ID Number

Have you contacted any other elected official regarding this case?

If yes, which elected official?

Please describe the nature of the problem you are experiencing in detail

Please attach any relevant documentation to this form

One file only.
100 MB limit.
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By signing this form, I am hereby authorizing the Office of State Senator James Skoufis to discuss and or receive information, records and documentation regarding my case

Signature

By signing this form, I am hereby authorizing the Office of State Senator James Skoufis to discuss and or receive information, records and documentation regarding my case:

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