Response

Name/Nombre Legal

Prefix

First Name

Last Name

Address Line/Domicilio

City/Ciudad

State

ZIP Code/Código Postal

Home Phone/Teléfono de su domicilio

Cell Phone/Teléfono cellular

Work Phone/Teléfono de su trabajo

Date of Birth/Fecha de nacimiento

FAX

Is your claim considered a total loss claim as a result of the Hermit's Peak/Calf Canyon Fire?

Did you lose your primary residence?

If you lost your primary residence, what is your current housing situation?

Is your claim overdue in that it is beyond 180 days?

Have you had to get an extension on any part of your claim?

Have you received a Letter of Determination that hasn't been paid out yet?

How long have you waited?

Do you have third-party representation?

Have you had to work with more than one navigator on your claim?

How many and why?

When did you last hear from the Claims Office about your claim?

How long has it taken to get an update or responses from the Claims Office?

Have you received a partial payment?

Provide any additional information you feel is helpful to know

Include the following information only if you request that Sen. Luján's office open up a case on your behalf to submit a Congressional inquiry if you haven't already opened up a case:

Social Security Number

Claim Number:

I hereby request and authorize United States Senator Ben Ray Luján and/or members of his staff, to make an inquiry on my behalf in addressing this matter. I further understand that I will save harmless any agencies divulging information pursuant to this release of information, as well as Senator Ben Ray Luján and/or any member of his staff in these matters.

Por lo presente solicito y autorizo al Senador de Los Estados Unidos Ben Ray Luján y/o miembros de su personal, hacer una investigación en mi nombre para afrontar este asunto. Además entiendo que evitare daños a las agencias, al Senador de Los Estados Unidos Ben Ray Luján y/o miembros de su personal por divulgación de información e inconformidad por dar a conocer la información referente a este asunto.

In addition to Senator Luján's office, I have also requested assistance from/Además de la oficina del Senador Luján, también he solicitado la asistencia de:

In a few sentences, please describe what my office can assist you with.

Today's Date

Would you like to receive Senator Lujan's Email Newsletter?

Please attach a typed or clearly written description of the problem and any relevant documentation, no larger than 15MB a piece. Por favor incluya por escrito un descripción o recuento de lo sucedido y cualquier otra información pertinente.

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