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Constituent Response Form |
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Please print this form out, mail it and/or forward copies of
additional material to:
The Stegmaier Building
7 North Wilkes-Barre Boulevard
Suite 400 M
Wilkes-Barre, PA
18702-5283
You can fax information to my Wilkes-Barre
office at 570-825-8685. For more information, please call my Wilkes-Barre office at 570-825-2200.
Name:
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______________________________________________________________ |
Street Address:
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______________________________________________________________ |
City:
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______________________________________________________________ |
Zip:
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______________________________________________________________ |
Home Phone:
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__________________ Business Phone: ________________________ |
Social Security
Number:
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______________________________________________________________ |
Date of Birth:
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______________________________________________________________ |
Type of Case (black
lung, social security,
etc):
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______________________________________________________________ |
Other identifying
or claim numbers:
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______________________________________________________________ |
If this inquiry relates to survivor's benefits,
please provide the following information on the deceased:
Name:
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___________________________________________________________ |
Social Security
Number:
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___________________________________________________________ |
Date of Birth:
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___________________________________________________________ |
Date of Death:
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___________________________________________________________ |
Type of Case (Black
Lung, Social
Security, etc.):
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___________________________________________________________ |
Other identifying
or claim numbers |
___________________________________________________________ |
Please describe
your problem
briefly:
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___________________________________________________________
___________________________________________________________
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What would like
Congressman Kanjorski
to do to help
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___________________________________________________________
___________________________________________________________
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"I understand that in order for you to
respond fully to my request, it may be necessary for you or your staff to
review those federal records that contain information you will need to assist
me. By signing this form, I hereby authorize the appropriate federal agencies
to release to you such information as you may require."
Signature __________________________ Date:___________________________
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