U.S. Congressman Scott DesJarlais

Representing the 4th District of Tennessee

Help with a Federal Agency

One of the most important things I do as a U.S. Representative is help people with federal casework. Although I cannot override the decisions made by a federal agency, I can often intervene on a person's behalf to answer questions, find solutions, or just cut through the red tape.

Individuals residing in the 4th Congressional District of Tennessee can contact my office for assistance in dealing with Federal agencies. In order to assist you, I will need you to complete a privacy authorization form to comply with the provisions of the Privacy Act. Please complete the printable version of the privacy authorization form below and then fax or mail to the address listed under the completed form.

Please include all pertinent information and claim numbers in your correspondence—such as:

Your Social Security number for a case involving Social Security;
VA claim number for a case with Department of Veterans Affairs;
Taxpayer identification number (Social Security number, if individual) for an Internal Revenue Service problem, etc.;
Your address, home phone number and daytime phone number (if different than home) so that we can obtain any additional information from you that might be necessary;
Copies of any related documents or correspondence that you may have from the agency involved;

Please Note:

The Privacy Act of 1974 (5 U.S.C. § 552a) requires that Members of Congress or their staff have written authorization before they can obtain information about an individual's case.
We must have your signature to proceed with this type of request.

Privacy Release Form

indicates information that you need to provide.

In accordance with the Privacy Act of 1974, I give Congressman Scott DesJarlais' authority to act on my behalf.

Your Information

Today's Date:

Full Name:

Agency Involved:

Branch of Service: (If Applicable)

Military Rank: (If Applicable)

Agency case number(s): (if there is no case number, indicate "None")

Date of Birth

Social Security Number

Street Address

City

State

Zip Code

Email:

Telephone

Telephone Number:

Voice VP TTD

What are these options?
This is to help the constituents that are hard of hearing or use a video phone alert us to that fact so we can use the proper technology when we need to call them. The default option “Voice” is a normal audible telephone.

Nature of Problem

Please Explain

Print This Form

Use the Generate Request button to produce the document to authorize my office to help you. Then sign it and mail it to the address shown on the document. Please include any other documents or material that you think would help my office help you.