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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
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)