Authorization Form - Rep. Dave Camp

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Authorization Form

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 the Problem in Detail:

Third Party (optional. A person you designate, other than yourself, to give and receive information pertaining to your situation.)
Third Party Name:

Third Party Address:

Third Party Phone: