Congressman Tom McClintock

Representing the 4th District of California

Agency Help

Residents of the 4th Congressional District of California can contact me for assistance in dealing with Federal agencies. In order to better serve you, this form 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;
Your Alien Registration Number for an immigration related case;
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 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.

Please send the form to: Office of Congressman Tom McClintock, 2200A Douglas Blvd., Suite 240, Roseville, CA, 95661

Authorization Form

* indicates information that you need to provide.

In accordance with the Privacy Act of 1974, I give Congressman Tom McClintock 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 or Alien Registration Number

Street Address

City

State

Zip Code

Email:

Telephone

Daytime Telephone Number:

Voice VP TTD

Alternate Telephone Number:

Voice VP TTD

Fax Number:

What are VP/ TTD options?
This is to help constituents who are hard of hearing or use a video phone to 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.

Have you contacted another Congressional office regarding this matter Yes
No

If "yes" to the above question, which office and when?

Nature of Problem

Text of Message:

Use the Generate Request button to produce the document to authorize my office to help you. Then sign it and mail or fax to the address / fax number shown on the document. Please include any other documents or material that you think would help my office help you. Please send or fax the form to: Office of Congressman Tom McClintock, 2200A Douglas Blvd., Suite 240, Roseville, CA, 95661 or fax to 916-786-6364.

PDF Version of the Authorization Form

Congressman Tom McClintock

Representing the 4th District of California

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Agency Help

Please Note:

Authorization Form

Washington, D.C. Office

Roseville District Office

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