Constituent Consent & Information - Print Form
Date: [date]
Agency involved: [required-agency]
Numbers Identifying Case (VA claim, Alien number, tax ID, etc.): [required-numidcase]
Name: [required-name]
Branch of Service (If Applicable): [branchOfService]
Military Rank (If Applicable): [militaryRank]
Place and Date of Birth: [required-birth]
Social Security #: [required-ssnum]
Street Address: [required-address]
City, State, Zip Code: [required-city], [required-state] [required-zip]
Telephone #: [required-phone] [speech]
Email Address: [email]
Do you have an attorney? [required-attorney]
If Yes, Attorney Name and Phone Number: [attynamenumber]
I, [required-name] certify under penalty of perjury, that I authorize Congressman Robert C. "Bobby" Scott, representative of the 3rd District of Virginia, and/or his staff to request any relevant information in order to assist in responding to my inquiry, in accordance with the provisions of the law. All information provided to Congressman Scott is complete, true and correct.
Nature of Problem: [required-problem]
[required-name]
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.
Signature: ___________________________________
Date:_______________________________________
Please print, and then mail or fax your request to the District Office:
Office of Congressman Bobby Scott
Attn: Constituent Services
2600 Washington Ave, Suite 1010
Newport News, VA 23607
Phone: (757) 380-1000
Fax: (757) 928-6694