Casework Assistance

Date

Name

Address

City/Zip Code

Telephone:
Home
Work
Fax
e-mail

Social Security Number

Veteran Case
Identification

CSA Number

Additional comments/case specifics:








I hereby give Senator Charles E. Schumer permission to make an inquiry into my claim now being processed at (name of agency):

 

Signature

Note: In order to comply with provisions of the Privacy Act of 1974 and to be of assistance with your claim(s), it is necessary that your signature be on file. After printing, please sign this form and return to our New York Office at the following address

Senator Charles E. Schumer
757 Third Avenue
Suite 17-02
New York NY 10017