Congressman Brad Sherman

Casework Authorization Form

NAME __________________________________________ DATE _______________________

ADDRESS ____________________________________________________________________

CITY AND ZIP ________________________________________________________________

PHONE (days) __________________________ (evenings)______________________________

FEDERAL AGENCY INVOLVED ________________________________________________
(e.g., Social Security, VA, Passport Agency, etc.)

IDENTIFYING NUMBER _______________________________________________________
(e.g., Social Security Number, case or claim number, etc.)

Please briefly describe below the type of assistance you are requesting and attach copies of any documents related to your case.

I authorize Congressman Brad Sherman and his staff to inquire on my behalf regarding my case and to receive information relating to it.

Signature _____________________________________________ Date _________________

Please return to:

Congressman Brad Sherman
5000 Van Nuys Boulevard, Suite 420
Sherman Oaks, CA 91403
Tel. (818) 501-9200 - Fax (818) 501-1554