Date: ____________________

Dear Congressman Hoekstra,

I request your assistance in resolving the problems I am having with (name of agency):

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Give highlights, necessary dates and locations.  Use second sheet if necessary.

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In keeping with the restrictions of the Privacy Act, you are authorized to request any information required to assist me.  I understand that any information on this form may be provided to the agency listed above in an effort to seek resolution of my problem.

Printed Name ______________________________Phone (Home) ______________________

Signature _________________________________ Phone (Work) ______________________

Address _____________________________ City _______________State ______ Zip _____

Social Security # __________________VA Claim # ______________ INS # A-____________