What state agency is handling your issue, or you are having an issue with?  *

Please describe the issue you are having.

Have you contacted another elected official regarding this issue?  *

Yes

If you have contacted another elected official regarding this issue, who did you contact?

Please provide your preferred contact phone number.  *

Please provide your preferred contact e-mail address.  *

Please provide your date of birth.  *

Please provide (if applicable) any case numbers, account numbers, or any other method the state agency may have given you to reference your case.

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.

I agree to the privacy and release of information statement above. I also understand and agree I may be asked to fill out further release of information documents as required by the state agency.  *

I agree

I disagree

Assemblymember Juan Alanis22nd Assembly District

Assemblymember Juan Alanis
22nd Assembly District