Constituent Service Request Form - Printable

STOP! Is this request urgent or have a time sensitive deadline? If mail comes to DC it takes UP TO 12 days to get here, in addition to the 6-8 week response. If so, please call one of my district offices: Bowling Green Office (419) 354-8700 or Defiance Office (419) 782-1996.

Name:

Prefix	First Name	MI	Last Name	Suffix (Jr., Sr.)

Address:

City:

State: Zip:

Email:

Phone:

Agency involved:

Claim #:

The following personal information will help our staff track your claim.

Date of birth: Social Security #:
Immigrant visa #: Alien card #:
Veteran #:Service record #:

Description of problem.

Privacy Act Statement

Under the Privacy Act of 1974, we must have formal authorization from you before seeking disclosure of your records. The authorization must be signed by the person whose case is in question.

In accordance with the Privacy Act of 1974 (5 USC 552), I hereby authorize Representative Bob Latta and his designated staff to seek disclosure of all records relevant to my case from the federal agency involved.

Signature:

Date:

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Washington Office: 1531 Longworth House Office Building | Washington, DC 20515 | Phone: (202) 225-6405 | Fax: (202) 225-1985 |

Ohio toll free number 800-541-6446 (OHIO) | Ohio toll free fax 800-278-8203

Bowling Green Office: 1045 N. Main Street, Suite 6 | Bowling Green, Ohio 43402-1361 | Phone:(419) 354-8700 |

Defiance Office: 101 Clinton Street, Suite 1200 | Defiance, Ohio 43512-2165 | Phone:(419) 782-1996 |

Norwalk Office: 130 Shady Lane Drive | Norwalk, Ohio 44857 | Phone:(419) 668-0206 |