Congressman Wayne Gilchrest
1st Congressional District, Maryland

Name __________________________________________________________

Full Postal Address ________________________________________________

Home phone _________________ Business phone _______________________

Please complete blanks where applicable:


Social Security Number ______________________________________________

Veterans Claim Number ______________________________________________

Military Identification Number ___________________________________________

Other numbers identifying your case _____________________________________

Types of benefits I am seeking __________________________________________

Date and Place claim was filed _________________________________________

Federal agency involved _______________________________________________

Additional information/explanation of request:  


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In accordance with the provisions of the Privacy Act, I hereby authorize Congressman Wayne Gilchrest or a member of his staff to make the appropriate inquiry on my behalf.

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(Signature)