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1045 North Main St, Ste 6
Bowling Green, OH 43402
101 Clinton St, Ste 1200
Defiance, OH 43512
11 East Main Street
Norwalk, OH 44857
Ohio Toll Free Fax (800) 278-8203
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 Robert Latta or a member of his staff to make the appropriate inquiry on my behalf.
Sincerely,
_______________________________________________
(Signature)