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Help with a Federal Agency Form

Residents of Michigan's 15th Congressional District can contact Congressman Dingell for assistance in dealing with Federal agencies. In order to better serve you, this form will generate a printable page that you should sign and mail to Congressman Dingell's office in Dearborn.

Please include all pertinent information and claim numbers in your correspondence—such as:

Your Social Security number for a case involving Social Security;
VA claim number for a case with Department of Veterans Affairs;
Taxpayer identification number (Social Security number, if individual) for an Internal Revenue Service problem, etc.;
Your address, home phone number and daytime phone number (if different than home) so that we can obtain any additional information from you that might be necessary;
Copies of any related documents or correspondence that you may have from the agency involved.

Please Note: The Privacy Act of 1974 (5 U.S.C. § 552a) requires that Members of Congress or their staff have written authorization before they can obtain information about an individual's case. Congressman Dingell's office must have your signature to proceed with this type of request.

Authorization Form

* marks required fields of data.

In accordance with the Privacy Act of 1974, I give Congressman John Dingell authority to act on my behalf.

Today's Date
* Full Name
* Agency Involved
Branch of Service (If Applicable)
Military Rank (If Applicable)
* Agency case number(s) (if there is no case number, indicate "None")
* VA claim number (if there is no case number, indicate "None")
* Date of Birth
* Social Security Number
* Street Address
* City, * State, * Zip Code	,
* Telephone No.
Email
* Please provide a brief description of your problem
* Have you contacted any other Government agencies or organizations to seek assistance with this? If so, who did you contact and what was the result?
* How can Congressman Dingell assist you with this matter?

Print This Form

Use the Generate Request button to produce the document to authorize my office to help you. Then sign it and mail it to the address shown on the document. Please include any other documents or material that you think would help my office help you.

Representative John Dingell

Representing the 15th Congressional District of Michigan

Help with a Federal Agency Form

Authorization Form

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