Print
this form and fax or mail to:
THE OFFICE OF CONGRESSMAN DAVE LOEBSACK,
125 S. Dubuque Street,
IOWA CITY, IA 52240,
PHONE: 319.351.0789,
FAX: 319. 351.5789
Date________________________________________
Name_______________________________________________________________________________
Address_____________________________________________________________________________
City, State, Zip_______________________________________________________________________
Home Phone ________________________ Work Phone___________________________________
Social Security #___________________________ Date of Birth ______________________________
Agency Involved______________________________________________________________________
Numbers Identifying Case (VA claim, Alien number, tax ID, etc.) ______________________________
Date and Place Claim was Filed__________________________________________________________
Please describe problem in detail _________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
In accordance with the provisions of the Privacy Act, I hereby authorize Congressman or a member of his staff to make the appropriate inquiry on my behalf.
Sincerely,
_______________________________________________
(Signature)