Date _________________________________
Social Security No. ______ - ______ - _______
Claim No. ______________________________
SRC/A No. _____________________________
Dear Senator Sessions:
I request your assistance in resolving the problem I am having with (agency)
Give highlights, necessary dates and locations. Use second sheet if needed.
In keeping with the restrictions of the privacy act, you are authorized to request any information required to assist me.
Name: (printed) _________________________________________________
Address:__________________________________________________________________
_________________________________________________________________________
Home Phone: _____________________ Work __________________________
Signature: ___________________________