By completing this form, I am requesting the Office of Assemblymember Juan Alanis (the “Assemblymember”) to assist me in working with the provided state agency to resolve my issue. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize the state agency and the Assemblymember to share all relevant portions of my records with each other, and to discuss matters relating to those records and my claim, until my claim is resolved.
I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Assemblymember’s office needs additional information, the office will contact me to request that information.