Intake Form

To be able to submit this form, please first enter your address below to verify you are in our district.

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Please confirm your email. *

If you do not have an email address, please write N/A.

Please confirm your phone number. *

Date of Birth: *

Which California state agency do you need assistance with? *

California Department of Insurance (CDI)

Employment Development Department (EDD)

Franchise Tax Board (FTB)

California Housing and Community Development (HCD)

California Department of Justice (DOJ)

Department of Motor Vehicles (DMV)

Other

If you selected other, please specify here.

Applicable Case/Application/Identification Number with the agency (if applicable):

Date of application or first contact with the agency (if applicable):

Have you contacted the agency? *

Yes

When was the last time you received correspondence from the agency?

Have you contacted another elected official? *

Yes

If yes, who have you contacted?

Please provide a detailed summary of the issue you are requesting assistance with. *

Acknowledgement of Request for Assistance

The Office of Assemblyman James Gallagher requires concent to work with the requested state agency on your behalf. If additional personal identifying information is needed (i.e. social security number, deriver's license number, EDD customer account number, etc.) a signed Release of Information form is requried and will be sent to you by staff.

By clicking here, you agree to these terms. *

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