Casework Authorization Form

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CASEWORK AUTHORIZATION FORM
PRIVACY RELEASE
MARCIA L. FUDGE
U.S. MEMBER OF CONGRESS
Please Email, Fax or Mail your completed form via U.S. Postal Mail service at:
4834 Richmond Road, Warrensville Heights, OH 44128
Phone: 216-522-4900
Fax: 216-522-4908
CASEWORKER
________________________
NAME: _____________________________________________________________________________
First
M.I.
Last
ADDRESS:
________________________________________________________________________
Street
Apartment Number
________________________________________________________________________
City
State
Zip
PHONE: _______________-_____________________-__________________________
SOCIAL SECURITY#: ___________-________-____________
Date of Birth:_____________________________________________________________
Have you contacted other Congressional Offices regarding your issue? If so, when & what was the
outcome? ___________________________________________________________________________
I RESPECTFULLY REQUEST AND AUTHORIZE REPRESENTATIVE MARCIA L. FUDGE , AND OR HER STAFF
TO PLACE AN INQUIRY ON MY BEHALF AND TO RECEIVE INFORMATION FROM THE PROPER
OFFICIALS REGARDING MY CONCERNS.
SIGNED: _________________________________________
DATE:
______
NOTE: THE PRIVACY ACT (5 USC 552a (b)) REQUIRES THE COMPLETION OF THIS FORM IN ORDER FOR
CONGRESSWOMAN MARCIA L. FUDGE TO RECEIVE INFORMATION ON BEHALF OF CONSTITUENTS.

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