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Congressman Justin Amash
Please print, sign and mail/fax to our office.
Name: [required-name]
Date: [required-date]
Agency involved: [required-agency]
Numbers Identifying Case (VA claim, Alien number, tax ID, etc.): [required-numidcase]
Branch of Service (If Applicable): [branchOfService]
Military Rank (If Applicable): [militaryRank]
Date of Birth: [required-birth]
Social Security #: [required-ssnum]
Street Address: [required-address]
City, State, Zip Code: [required-city], [required-state] [required-zip5] [zip4]
Telephone #: [required-phone] [speech]
Email Address: [required-valid-email]
Nature of Problem: [required-problem]
The section below is to be completed by the person who is the subject of the records:
I, (print your name) _______________________________________, authorize United States Representative Justin Amash, and the members of his office, to act on my behalf and to receive information from the relevant agencies and officials regarding the matter described above.
I certify that 1) I provided or authorized all of the information in this privacy release and any document submitted with it; 2) I reviewed all of the information contained in and submitted with my privacy release; and 3) all of this information is complete, true, and correct, to the best of my knowledge.
Signed: ___________________________________________________ Date: ________________
Print, and then mail or fax your request to Congressman Justin Amash at the following address.
Please mail your form to:
Office of Congressman Justin Amash
Attn: Constituent Services
110 Michigan St., Suite 460
Grand Rapids, MI 49503
Phone: (616) 451-8383
Fax: (616) 454-5630