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Congressman Bobby Scott

Representing the 3rd District of Virginia

Constituent Consent & Information Form

In order for my office to assist you, please fill out the consent and information form below.

Please Note:

Under the Privacy Act of 1974, we must have formal authorization from you before seeking disclosure of your records. The authorization must be signed by the person whose case is in question.

In accordance with the Privacy Act of 1974 (5 USC 552), I hereby authorize Representative Robert C. "Bobby" Scott and his designated staff to seek disclosure of all records relevant to my case from the federal agency involved.

In order to better serve you, this form will generate a printable page that you should sign and mail or fax to my District Office:

District Office
2600 Washington Ave, Suite 1010
Newport News, VA 23607
Tele: (757) 380-1000
Fax:  (757) 928-6694

Authorization Form

*indicates information that you need to provide.

In accordance with the Privacy Act of 1974, I give Representative Robert C. "Bobby" Scott authority to act on my behalf.

Your Information
Telephone
 
 

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

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.