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this form and fax or mail to:
DALTON, GA OFFICE
702 South Thornton Avenue
Dalton, GA 30720
T (706) 226-5320
F (706) 278-0840
-OR-
ROME, GA OFFICE
600 E. First Street Suite 301
Rome, GA 30161
T (706) 290-1776
F (706) 232-7864
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 Graves or a member of his staff to make the appropriate inquiry on my behalf.
Sincerely,
_______________________________________________
(Signature)