Print this form and fax or mail to:
173 N. Main Street Jonesboro, GA 30236 f. (770) 210-5673

Authorization Sheet

 

Date________________________________________

 

Name_______________________________________________________________________________

 

Address_____________________________________________________________________________

 

City, State, Zip_______________________________________________________________________

 

Home Phone ________________________       Work Phone___________________________________

 

Social Security #___________________________   Date of Birth  ______________________________

 

Agency Involved______________________________________________________________________

 

Numbers Identifying Case (VA claim, Alien number, tax ID, etc.) ______________________________

 

Date and Place Claim was Filed__________________________________________________________

 

Please describe problem in detail _________________________________________________________

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

In accordance with the provisions of the Privacy Act, I hereby authorize Congressman David Scott or a member of his staff to make the appropriate inquiry on my behalf.

 

Sincerely,

 

_______________________________________________

(Signature)