Congressman Pete Hoekstra - IRS Release Form

IRS Privacy Act Release

I request the Internal Revenue Service to disclose to Congressman Pete Hoekstra the information described below from IRS records concerning:

Name of Taxpayer: ______________________________ Phone (H): ____________________

Address: ______________________________________ Phone (W): ____________________

City: ______________________________ State: ________ Zip: _________________

Social Security #: ______________________________ Employer ID#: ___________________

Kind or Type of Return: ________________________ Taxable Period Ending: ______________

I request disclosure of the following described information. (Describe returns and/or specific information to identify problem. Use second sheet if necessary.)

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I understand that any information on this form may be provided to the IRS in an effort to seek resolution of my problem. I impose the following limitations concerning the disclosure of this information. (If none, so state.)

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Printed Name _____________________ Signature ______________________ Date _______