Fillable Casework Authorization Form printable pdf download

Casework Authorization Form

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D.C. Congressional Office

District Congressional Office

Congressman David G. Reichert

1730 Longworth Building

22605 SE 56

St, Suite 130

Washington DC 20515

Member of Congress

Issaquah, WA 98029

Phone: 202-225-7761

Washington’s 8

Congressional District

Toll Free: 877-920-9208

Fax: 202-225-4282

Phone: 425-677-7414

Fax: 425-270-3589

Casework Authorization Form

Please print legibly

Full Name:

Date of Birth:

on behalf of:

…

Social Security #:

(if applicable)

Relationship:

Home Phone #:

(if applicable)

Mobile Phone #:

Work Phone #:

E-mail:

Fax #:

Physical Address:

Mailing Address:

(if different)

City:

State:

Zip Code:

Claim/File #:

(LIN # / Case # / Alien # / File #, etc.)

Federal Agency(ies) involved:

Constituent Permission

Please Note: The Privacy Act requires that you authorize access to your private records and authorize this office to release

information. Without your authorization, an inquiry on your behalf will not be possible.

Desired Resolution:

Please give a detailed description of your situation with the specified federal agency.

(Please feel free to use additional sheets of paper):

I hereby request the assistance of the Office of United States Representative David G. Reichert in resolving the

matter described in this document and I authorized Reichert and his staff to receive and/or release any

information needed to provide assistance.

Signature:

Date:

Please print and fax or mail to our District Office along with copies of any other documentation that you

think might be helpful to us when making an inquiry on your behalf. We are not permitted to accept

gifts for any services you receive. We look forward to assisting you. Thank you.

Casework Authorization Form

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