Help with a Federal Agency - Print Form
Representative Joe Wilson
Please print, sign and mail/fax to my office.
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]
I, [required-name], authorize the [required-agency] to release personal information to Representative Joe Wilson United States Representative. I authorize Representative Joe Wilson to request and have access to all records and reports pertinent to my request for his assistance in the following matter:
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:_______________________________________
Print, and then mail or fax your request to Representative Joe Wilson at the following address.
Please mail your form to:
Office of Representative Joe Wilson
Attn: Constituent Services
1700 Sunset Blvd (US 378), Suite 1
West Columbia, SC 29169
Phone: (803) 939-0041
Fax: (803) 939-0078