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My office is happy to assist you in all of your needs.
However, to facilitate your request, please send the form below my office.
Make sure that you sign it; without a signature, we will not be able to help
you. Please print out the form, complete, sign, and mail it to the address listed below.
Name: ______________________________________________________________________
Address: ____________________________________________________________________
City and Zip Code: ____________________________________________________________
Daytime phone: ____________________ Evening phone: ____________________
Fax number: ____________________ Email: ____________________
Social Security number: ____________________
Please provide any other tracking numbers relevant to your case, such as Veteran Case Identification number, CSA number,
IRS number, INS number:
________________________________________________________________________
Federal agency you need help with: __________________________________________
Brief description of the problem (attach more pages if necessary):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
I hereby request the assistance of the Office of United States Representative
Ellen O. Tauscher in addressing the matter described above, and authorize Rep.
Tauscher and her staff to receive any information which they may need in order to provide this assistance.
______________________________________________
Signature* and Date
*Note: In order to comply with the provisions of the Privacy Act of 1974 and to be of assistance with claim(s), it is necessary that your signature be on file.
Please print and mail or fax to:
Rep. Ellen O. Tauscher
Attention: Casework
2121 N. California Blvd., Suite 555
Walnut Creek, CA 94596
(925) 932-8159 fax
(please attach copies of any supporting documents)
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