U.S.

Senator Rick Scott

Privacy Act Consent Form
By providing the information below and signing this form, I hereby authorize Social Security Admin. (Agency Name)
to furnish Senator Rick Scott’s Office information pertaining to my claim or request. This authorization is in accordance
with the Privacy Act of 1974 (Public Law 93-579).
Al proporcionar la información a continuación y firmar este documento, autorizo por la presente a N/A
(nombre del agente) a proveer información a la oficina del Senador Rick Scott relacionada con mi reclamo o solicitud. Esta
autorización está en conformidad con la Ley de Privacidad de 1974 (Ley Pública 93-579).

Prefix/ Prefijo: Mr. Ms. Mrs. First Name/Primer Nombre: Rita

Middle/Segundo Nombre:Lynn Last Name/Apellido: Williams

Suffix/ Sufijo: Sr. Jr. II III Date of Birth/Fecha de Nacimiento: 03/28/1951

Place of Birth/ Lugar de Nacimiento: Jacksonville, Florida
Work Phone/ Teléfono Trabajo:N/A Cell/ Celular: 904-502-7320
Email/ Correo Electrónico: ritawilliams351@gmail.com
Address/ Dirección: 4894 Inca Court
City/ Cuidad:Fleming Island State/ Estado:Fl Zip Code / Código Postal: 32003
Social Security # (Not required for USCIS/Medicare inquiries / Número de Seguro Social (no requerido para
USCIS/casos de Medicare): 265-94-4302 Medicare #
VA # (if applicable)/ Identificación de Veterano: N/A
Alien # (if applicable)/ Número de Extranjero: N/A
Immigration Case #/ Número de Caso: N/A

Please add me to Senator Rick Scott’s E-Newsletter/ Por favor suscríbame al boletín electrónico del Senador Rick Scott

Briefly state your problem and how you would like Senator Scott to assist you.
This is required. / Describa brevemente su problema y cómo le gustaría que el
Senador Scott le ayudara. Esto es necesario.
My husband, Jack Dwane Williams, Social Security #480-34-9825, died last year on October 23,
2021. As reminded by the funeral home, I applied for Jack’s Social Security because his monthly
allowance is much larger than mine, and it is my only source of income. My husband was a decorated
Marine Corp Korean War pilot,who flew for Eastern Airlines for 34 years ending his career in 1991
upon the bankruptcy of Eastern Airlines. In 2000 the bankruptcy court opted to abolish Jack’s
insurance policy, and spouse’s survivors benefits. Thus,after Jack’s extended Illness, leaves me in a
very sad situation.
Since November, 2021, I have promptly complied with all of the Social Security requests, and was
told months ago that my fill was in the local Jacksonville office for approval. Each time I call the
Jacksonville, Fl office the call is forwarded back to the main umber where after many questions I’m
told that I have to speak with the Jacksonville office. Senator Scott, this has gone on for months, and
as a retired manager I find this very frustrating. Not to mention that the little savings we had is being
eaten away, and my future is scary.
Governor Scott, I greatly appreciate anything that you can do to help me get this matter resolved.
With prayers for you and your family during these trying times. May God bless our great country.

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Signature/ Firma: Date/ Fecha:

Signature must be from an individual who is 18 years of age or older and is requesting assistance or has a case pending with a federal
agency. Third party signatures of any kind are not valid. Electronic signatures are not valid.
La firma debe ser de un individuo de 18 años de edad o más y que esté solicitando asistencia o tenga un caso pendiente con una
agencia federal. Las firmas de terceras personas no son válidas. Las firmas electrónicas no son válidas.

FOR INQUIRIES TO UNITED STATES CITIZENSHIP AND IMMIGRATION SERVICES (USCIS), in

accordance with 6 C.F.R.5.21(d): I,
certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy release
form and any document submitted with it; 2) I reviewed and understand all of the information contained
within this privacy form and submitted with it; and 3) all of this information is complete, true, and correct.

PARA LAS CONSULTAS A LOS SERVICIOS DE CIUDADANÍA E INMIGRACIÓN DE LOS ESTADOS

UNIDOS (USCIS), de acuerdo con 6 C.F.R.5.21 (d):
Yo, , certifico, bajo pena de perjurio, que
1) proporcioné o autoricé toda la información en este documento de privacidad y cualquier documento
presentado con el mismo; 2) revisé y entiendo toda la información contenida en este documento de
privacidad y documentos presentados con el mismo; y 3) toda esta información es completa, verdadera y
correcta.

Signature/ Firma: Date/Fecha:

Please return this form using one of the following methods:

 Fax 202-228-4535
 Email casework@Rickscott.senate.gov
 U.S. Mail to the office nearest you.
Por favor devuelva este formulario utilizando uno de los siguientes métodos:
 por fax 202-228-4535
 por correo electrónico a casework@Rickscott.senate.gov
 por correo a la oficina más cercana a usted

502 Hart Senate Office Building, Washington, DC 20510 | (202) 224-5274

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5274
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