Release Form

ffice of Senator Ossoff can assist you in the matter below.

Pursuant to the Privacy Act of 1974, our office cannot assist individuals without their express written consent

Full Name: Robert Corey Segars

Date of Birth: 07 08 1976 : 478-443-1687
Email:
Coreysegars1@gmail.com
Address: 1611 Flat Shoals Rd.
City: Milledgeville Ga Zip: 31061
If applicable, please provide the following information:
DCA Emergency rental assistance 253-65-7476

Nature of Problem: Please below regarding the nature of your problem and the
assistance you are seeking.

Currently been submitted documents in september me and my family now living in hotel and yet still processor is
Acting slow! Landlord does not want to participate need funds for roof over our head 3 weeks ago!! Please help im
desperate!!

request and authoriz Senator Jon Ossoff o intercede on my behalf,

including the right to review all appropriate 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 above. I understand that any
documents I provide to Senator Jon Ossoff or his staff may be copied and forwarded to officials of the agency listed
above for review.

I hereby authorize the Office of Senator Jon Ossoff to act on my behalf with any federal agency relevant to the
matter described above, and therefore waive all rights in the release of any and all related information and records.

Signature: Date:
11/11/2022