Authorization Form

Print this form and fax or mail to:

Washington, DC Office
507 Cannon HOB
Washington DC 20515
T (202) 225-5905
F (202) 225-5396

Moline Office
3000 41st St Suite 2
Moline IL 61265
T (309) 757-7630
F (309) 757-7638

Galesburg Office
185 South Kellogg St
Galesburg IL 61401
T (309) 343-2220
F (309) 343-2225

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 Congressman Schilling or a member of his staff to make the appropriate inquiry on my behalf.

Sincerely,

_______________________________________________

(Signature)