Assistance with a Federal Agency

If you can't get an answer from a federal agency in a timely fashion, or if you feel you have been treated unfairly, our office may be able to help resolve a problem or get you the information you need. While we cannot guarantee you a favorable outcome, we will do our best to help you receive a fair and timely response to your problem.

Residents of the 21st Congressional District of California can contact us 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 our office.

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:

I understand that the provision of The Privacy Act of 1974 (5 U.S.C. § 552a) prohibit the disclosure of information of a personal nature from the files of an individual without his or her consent.  In accordance with the provisions of the Privacy Act and under penalty of perjury, I certify the information in this release and inquiry is true and accurate to the best of my knowledge and, I hereby authorize Congressman TJ Cox and his staff to receive any information from the above stated federal agency(s).
We must have your signature to proceed with this type of request. You will review, print, and sign the document after it's generated from the information you enter below. This form must be filled out in English.

 

Authorization Form

This is a three step process:

  1. Fill in the form with the required data, then click the “Generate Request for Review” button at the bottom of the page.  Or download the form here.  
  2. Review the form to ensure all data is accurate, then sign the form.
  3. Print, sign and then mail your request to TJ Cox at the following address:

    Congressman TJ Cox
    Attn: Constituent Services Director
    2117 Selma Street
    Selma, CA 93662

          Phone: (559) 460-6070
          Fax: (833) 284-9089

In accordance with the Privacy Act of 1974, I give Representative TJ Cox authority to act on my behalf.

* marks required fields of data.

Your Information
Attach additional pages if necessary and include copies of all relevant documents received from the federal agency with which you seek assistance. Do not send original documents, as we cannot ensure their safe return.

What are these options?
Constituents who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option "Voice" is a standard audible telephone.

Please do not include your social security number if your case inquiry is immigration-related. This form requires you to print, sign and mail, fax, or hand deliver the signed document. Your social security number will not be transmitted electronically.
Agency/Military Information
Immigration-related Information

Print This Form

Use the "Generate Request for Review" button below to produce the document to authorize our office to help you. Print, sign, and mail, fax, or hand deliver it to the address shown on the document. Please include any other documents or material that you think would help our office help you.