Legislator's name:

Address:

City, State, Zip:

Telephone number, with Area Code:

I, ________________________________________________, hereby grant
   (Print Your Name Here)

____________________________________________________________,
(Print Legislator's Name Here)

or any member of his/her staff, the authority to obtain copies, documents, and other necessary information on my behalf from:

____________________________________________________________,
(Print the Name of the Child Support Agency or Other Program Here)

as is necessary to complete my inquiry. I maintain the right to rescind this authorization at any time.

My Social Security Number:
Address:
County:
City, State, Zip:
Telephone number:

Thank you very much for your assistance and compliance with this request.

____________________________________________ Date_____________
(Your Signature Goes Here)

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