Please fill out all fields and a print form will be generated. Write in your social security number (required), sign the form (required) and fax it to the district office nearest to you.

I am aware that the Privacy Act of 1974 prohibits the release of information in my file without my approval. I hereby authorize Congressman Kurt Schrader or his representative to inquire with the following agency on my behalf:

* indicates required field.



Your Name:
Prefix First Name * MI Last Name * Suffix (Jr., Sr.)
* Your Address:
* City: State: Zip:
* Home Phone:
Cell Phone:
Work Phone:
* Email:
* Date of Birth:


* What do you need help with?:

If you have a claim number, or other identifier with the agency, please note it here:

* What specifically can my office help you with?:



Please note: By federal law (18 USC, Sec. 205), neither Congressman Schrader nor his staff can involve themselves in private legal matters or represent constituents in judicial proceedings.