Constituent Services

CONSTITUENT CONSENT AND INFORMATION FORM

   

   

City:      ,  VA  ZIP: 

Agency involved:       

Claim #:  

Do you have a lawyer?:       

If Yes, Lawyer's Name:  

Lawyer's Phone Number:

The following personal information will help our staff track your claim.

Privacy Act Statement

Under the Privacy Act of 1974, we must have formal authorization from you before seeking disclosure of your records. The authorization must be signed by the person whose case is in question.

In accordance with the Privacy Act of 1974 (5 USC 552), I hereby authorize Representative Robert C. Scott and his designated staff to seek disclosure of all records relevant to my case from the federal agency involved.

Signature:

Date:

  

If you are experiencing difficulties with a Federal Government agency and you would like assistance from my office, please contact my Newport News District Office at (757) 380-1000. A Caseworker will be assigned to you and allow your process to be handled effectively.  You will also be asked to complete a Constituent Consent and Information Form and fax or mail it to my Newport News Office:

Office of Congressman Robert C. “Bobby” Scott
2600 Washington Ave. Suite 1010
Newport News, VA 23607
(757) 380-1000
(757) 928-6694 FAX

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Youth PROMISE Act
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