Request for Assistance with a State Agency

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Have you reached out to another elected official about this issue? *

Yes

Have you previously reached out to my office about this issue? *

Yes

Which agency do you need assistance with? *

For help with EDD, visit: bit.ly/EDDAssistance

If you selected other, please specify here.

Have you contacted the agency to resolve this issue? *

Yes

Case number or claim number associated with this issue: *

Do NOT enter a Social Security or Driver's License number.

Describe the problems you have been experiencing. *

REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION

Please carefully read the following:

By completing this form, I am requesting the Office of Assemblymember Papan (the "Assemblymember") to assist me on a matter with the specified state agency. 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 specified 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 issue, until my issue 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, such as my Social Security number or Driver's License number, the office will contact me to request that information.

By clicking here, I accept and agree to the terms in this form. *

Your privacy is very important to us. By clicking submit, you are agreeing to the practices described in the Privacy and Conditions of Use.