Request Help with State Agency

To request assistance for an issue you are having with a state agency, please submit the following request form. Staff will follow up by email for additional information, if needed, and to provide updates. Due to the large volume of requests, please allow 5 business days before following up with our office.

For assistance with federal issues (i.e. SSI, visas and passports, etc.) please contact your U.S. Congressional Representative.

For assistance with county or city government, please reach out to your respective elected official. Please note that we are unable to intervene in disputes with private entities or legal matters pending in a court.

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Which California state agency do you need assistance with *

Please note we cannot assist with federal issues

Department of Motor Vehicles

EDD (Unemployment/Disability/Paid Family Leave)

Franchise Tax Board

California Department of Justice

Department of Industrial Relations (Workers Compensation)

Other

If you selected other, please specify here.

Applicable Case/Application/Identification Number

EDD Customer Account Number

For EDD cases only

Have you contacted the agency? *

Yes

Have you been in contact with another elected official regarding this issue? *

Yes

If yes, who have you contacted?

Please provide a detailed summary of the issue *

Authorization for Release of Information

I have sought assistance from the Office of Assemblyman Tri Ta on a matter which may require the release of information contained in records maintained by your agency and which may be prohibited from dissemination by law. I hereby authorize you to release all relevant portions of my records and to discuss matters relating to those records with Assembylman Tri Ta and with any authorized member of his or her staff until this matter is resolved.

Does the Office of Assemblyman Tri Ta have permission to work with the agency to resolve this issue on your behalf?
*