About the 14th
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Assistance with Social Security Adminstration & Dept. of Veteran Affairs
| Date | |
| Name | |
| Address | |
| City | State Zip |
| Home Phone | Work Phone FAX |
| Social Security # | Birthdate |
| Agency Contacts | |
| Identifying or Claim Numbers | |
| Please describe your problem and how my office can help you: | |
| Request | |
| Attach copies of any letters, documents, etc., that you feel will be
helpful in solving your problem. |
Date
TO WHOM IT MAY CONCERN:
Persuant to the provisions of 5, U.S.C. 552a (Privacy Act of 1974) PL 93-579, I hereby authorize the release of information from, or copies of, my medical or any other records or files pertaining to me, to Congressman Mike Doyle.
Signature: __________________________________
Send this request to:
Congressman Mike Doyle
225 Ross Street
5th Floor
Pittsburgh, PA 15219
Phone: 412-261-5091
Fax: 412-261-1983
* Information below to be filled out by Congressional office *
| Intake Person |
My office may be able to help you in your dealings with federal government agencies.
