Response

Gary’s office stands ready to help you understand your rights and responsibilities related to various federal programs and help you work through a problem you may have with a federal agency. Acting as a liaison between you and the federal government, our staff can often help you answer questions, find resources or resolve problems. Our office cannot promise you a specific outcome from an agency or referral. We will do our best to help you receive a full and fair response.

Please complete a separate form for each person seeking assistance.

The Privacy Act of 1974 (Public Law 93-579) requires your written authorization for my office to contact government agencies on your behalf or discuss your case in detail. The Privacy Act authorizes the disclosure of records to congressional offices acting on behalf of constituents only when the individual has consented.

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First Name

Last Name

Organization

Address Line 1

City

State

Zip

Home Phone

Work Phone

Cell Phone

Date of Birth

PLEASE PROVIDE THE APPLICABLE INFORMATION RELATED TO YOUR CASE

Social Security Number:

Medicare Number:

Veterans Affairs Claim Number:

Branch of Service:

Dates of Service Started in Month and Year:

Dates of Service Ended in Month and Year:

Passport #

Other numbers identifying your claim:

IRS Case #

Tax Year

Have you contacted another congressional office?

Which Offices?

Briefly describe the concern(s) or problem(s) you are having with a federal agency:

Describe the specific resolution you are hoping for:

I hereby authorize Senator Gary Peters and his staff to work on my behalf with any federal agency relevant to the matter described above, to receive and review any information contained in my file, and, if necessary, to forward any pertinent correspondence sent by me regarding this matter.

Written name for signature below:

Today's Date

Submit with the Release, a copy of the last agency decision, and any other documentation that will be helpful in my research on your behalf, up to three files and no larger than 15MB a piece. Please attach the effected tax return for IRS cases.

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