Casework Authorization Form

Please carefully read the following and sign below.

"I hereby request the assistance of the office of Congresswoman Stephanie Herseth Sandlin in resolving the matter described below and authorize Congresswoman Herseth Sandlin and her staff to receive any information which they may need in order to provide this assistance."

Signature:____________________________________ Date:

Signature of Spouse:___________________________ Date:
(required if information in spouse's file must also be released)
 

This information may also be released to the following person or people (for example: spouse, parent, representative):

Please enter the following information:

Name:

Address:

City:

State: Zip Code: -

Home Telephone:

Work:

Social Security Number:

Other Pertinent Identification Numbers:

Describe the situation for which you request assistance:

 


IMPORTANT - This form does not transmit information.
Please print this page, fill in the information, and send the completed form to:
Congresswoman Stephanie Herseth Sandlin
326 East 8th Street, Suite 108
Sioux Falls, SD  57104
Or call toll free: (866) 371-8747