Print this form and fax or mail to:
U.S. Representative Zoe Lofgren (CA-19) 635 North First Street, Suite B San Jose CA 95112 Fax: (408) 271-8715

 

Authorization Sheet

 

Date________________________________________

 

Name_______________________________________________________________________________

 

Address_____________________________________________________________________________

 

City, State, Zip_______________________________________________________________________

 

Home Phone ________________________       Work Phone___________________________________

 

Social Security #___________________________   Date of Birth  ______________________________

 

Agency Involved______________________________________________________________________

 

Numbers Identifying Case (VA claim, Alien number, tax ID, etc.) ______________________________

 

Date and Place Claim was Filed__________________________________________________________

 

Please describe problem in detail _________________________________________________________

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

In accordance with the provisions of the Privacy Act, I hereby authorize Representative Lofgren or a member of her staff to make the appropriate inquiry on my behalf.

 

Sincerely,

 

_______________________________________________

(Signature)