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Attn: Casework
U.S. Rep. Jack Kingston
One Diamond Causeway #7
Savannah, GA 31406
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 Congressman Jack Kingston or a member of his staff to make the appropriate inquiry on my behalf.
Sincerely,
_______________________________________________
(Signature)