Please print, sign and mail/fax to our office.

Name:

Date:

Agency involved: 

Numbers Identifying Case (VA claim, Alien number, tax ID, etc.): 

Branch of Service (If Applicable):

Military Rank (If Applicable):

Date of Birth:

Social Security #: 

Street Address: 
City, State, Zip Code: ,

Home Telephone #: 

Work Telephone #: 

Cell Telephone #: 

Email Address: 

I, , authorize the to release personal information to Congressman Alan Lowenthal United States Representative. I authorize Congressman Alan Lowenthal to request and have access to all records and reports pertinent to my request for assistance in the following matter:

Nature of Problem: 

Other agencies or organizations contacted regarding this matter, and the result of each: 

Other individuals associated with this case: 

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 a casework inquiry.