Authorization For The Release Of Information Under The Privacy Act
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1FOR SOCIAL SECURITY, VETERANS AND CIVIL SERVICE
U.S. Department of State
CONSULAR OFFICES OF THE UNITED STATES OF AMERICA
AUTHORIZATION FOR THE RELEASE OF INFORMATION UNDER THE PRIVACY ACT
In accordance with the Privacy Act (PL 93-579) passed by Congress in 1974, a U.S. Consular Office cannot release any
information regarding you to anyone without your written consent except as set forth in the Act. Please complete the
authorization below, specifying whom a U.S. Consular Office may contact and to whom to release information with
regard to your case. Please return the completed authorization to a U.S. Consular Office. Local language translations are
acceptable to facilitate completion of the form in English.
The U.S. Government, by providing the Authorization for the Release of Information Under the Privacy Act
Form, cannot under any circumstances compel an individual to complete and submit the form. PLEASE
CAREFULLY CONSIDER TO WHOM, AND WHAT INFORMATION IS BEING DISCLOSED.
IMPORTANT: You are not obliged to grant anyone access to information regarding you but failure to
provide the information requested on this form may make it more difficult, or impossible, for the
Department of State or the U.S. Consular Office to assist you.
NOMBRE / Full Name (Last, First, MI)
LUGAR DE NACIMIENTO:
Place of Birth (City, State/Province, Country)
Born At:
FECHA DE NACIMIENTO / Date of Birth
# DE APLICACION / CLAIM NUMBER
SSN/VA/OPM:__________________________________
VALOR DE BENEFICIOS/
BENEFITS AMOUNT: USD$ ______________________
I hereby request the U.S. Consular Office of the United States of America and the U.S. Department of State to create
a certification of my federal benefits to:
MINISTERIO DE RELACIONES EXTERIORES / COLOMBIAN MINISTRY OF FOREIGN AFFAIRS (TP7 VISA)
BANCO / FINANCIAL INSTITUTION: ___________________________________________________
DIRECCION DE ENVIO / MAILING ADDRESS
FIRMA - Signature of the Applicant
FECHA / Date (mm-dd-yyyy)
TELEFONO /
PHONE #:__________________________
PRIVACY ACT STATEMENT
This information is needed to assist you in your present need for consular services. The primary purpose for soliciting this
information is to establish your citizenship, identity, and entitlement to welfare protection services offered by the U.S.
Government.
The U.S. Department of State is committed to ensuring that any personal information received is safeguarded against
unauthorized disclosure. The data you provide is subject to the provisions of the Privacy Act (5 U.S.C. 552a). This means that
the U.S. Department of State will not disclose the information you provide unless you have given us written authorization to
do so, or unless the disclosure is otherwise permitted under the provisions of the Act or in accordance with our routine uses
published in Title 22 of the Code of Federal Regulations. The information solicited on this form may be made available as a
routine use to other government agencies for law enforcement and administrative purposes. For further information on routine
uses, please visit
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Parent category: Legal