Response

In keeping with the restrictions of the Privacy Act of 1974, I hereby authorize Senator Mullin and/or his representative to request information from agencies or departments on my behalf. This release does not constitute a power of attorney.

Prefix

First Name

Last Name

Organization

Address Line 1

City

State

Zip

Main Phone

Work Phone

Cell Phone

Date of Birth

PLEASE PROVIDE THE APPLICABLE INFORMATION RELATED TO YOUR CASE

I am requesting help with the following Federal Agency:

Social Security Number:

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

Have you contacted another congressional office?

Which Offices?

If release of information on your case to another party or your attorney is authorized, please specify:

IRS (Tax Problem)

Type of tax:

Tax Year

Tax Form:

If this is for a business:

EIN #:

Your relationship to the business:

IRS Case #

Medicare Number:

Branch of Service:

Passport #

Other numbers identifying your claim:

If hereby authorize of the Office of Senator Mullin and authorize Senator Mullin and his staff to work on my behalf with any federal agency relevant to the matter described above, to receive 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.

Upload FileNo file chosen

Sign using your mouse or finger...