[required-prefix] [required-first] [middle] [required-last] [suffix], please enter your date of birth and social security number, verify the rest of the information, print, sign and mail or fax the printed sheet(s) to the address/fax number below.
Congressman Pete Aguilar
Information from Step one:
Name: [required-prefix] [required-first] [middle] [required-last] [suffix]
Agency Involved: [required-agency]
Agency Case Number(s) (VA claim, A number or WAC number, tax ID, etc.): [required-case-number]
Name: [required-prefix] [required-first] [middle] [required-last] [suffix]
Branch of Service (If Applicable): [branchOfService]
Military Rank (If Applicable): [militaryRank]
Street Address: [required-address]
City, State, Zip Code: [required-city], [required-state] [required-zip5]
Telephone #: [required-phone] [speech]
Email Address: [required-valid-email]
I, [required-prefix] [required-first] [middle] [required-last] [suffix], authorize the [required-agency] to release personal information to Congressman Pete Aguilar United States Representative. I authorize Congressman Pete Aguilar to request and have access to all records and reports pertinent to my request for his assistance in the following matter:
Nature of Problem: [required-problem]
PLEASE NOTE:
The Privacy Act of 1974 requires that Members of Congress or their staff have written authorization before they can obtain information about an individual’s case. We must have your signature to proceed with a casework inquiry.
Signature: ___________________________________________________
Date: ___________________________________________________
Print, and then mail or fax your request to Congressman Pete Aguilar at the following address.
Office of Congressman Pete Aguilar
Attn: Constituent Services
1223 Longworth House Office Building
Washington, DC 20515
Phone: (202) 225-3201
Fax: (202) 226-6962
