Help with a Federal Agency Honorable David Jolly

DOWNLOAD PRIVACY AUTHORIZATION FORM

As your Representative in Washington, D.C., one of the most important services I can provide my constituents is to assist in their interactions with Federal agencies and help ensure you receive a fair and timely response to any issues dependent on action or deliberation from them. While we cannot guarantee you a favorable outcome, we will do our best to help you receive a fair and timely response to your problem.

If you are a constituent, you can contact me for assistance in dealing with Federal agencies. In order to better serve you, the form below will generate a printable page that you should sign and mail to my office.

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.

Authorization Form

*indicates information that you need to provide.

In accordance with the Privacy Act of 1974, I give Honorable David Jolly 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.

Please Note:

Authorization Form

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