State Agency Assistance Request

What State Agency do you need assistance with? *

Select one

Employment Development Department (EDD)

Department of Motor Vehicles (DMV)

Department of Healthcare Services (DHCS)

Franchise Tax Board (FTB)

State Controller's Office (Unclaimed Property)

Other

If you selected other, please specify here.

Please provide a brief description of your issue/request. *

Include any claim or reference numbers if applicable.

Have you reached out to my office regarding this issue before? *

Yes

Have you already reached out to the State Agency in an attempt to resolve this issue on your own? *

Yes

If so, when was the last time you were in contact with the State Agency?

Please provide your phone number and email so that we may have accurate information to contact you regarding your case.

First Name *

Last Name *

Address *

City *

Zip Code *

Phone Number

Ext.

Phone Number Type

Authorization for Release of Information

I have requested assistance from the Office of Senator Tony Strickland regarding a matter that may require access to information contained in records maintained by a government agency or other entity.

I hereby authorize any relevant agency, department, or organization to release to the Office of Senator Tony Strickland, including authorized members of his staff, any information, records, or documents necessary to assist with my inquiry or resolve this matter. This authorization includes the right to discuss my case and share relevant details until the matter is concluded.

I understand that some of the information requested may be considered confidential or protected by law, including but not limited to personal identifying information. By signing this form, I expressly consent to the release of such information for the purpose of facilitating assistance from the Senator’s office.

I acknowledge that:

- This authorization is voluntary.
- The information released will be used solely for the purpose of assisting with my request.
- I may revoke this authorization at any time by providing written notice to the Office of Senator Tony Strickland; however, such revocation will not apply to information already released.

If I choose to provide sensitive information such as my Social Security Number or Driver’s License Number, I understand that I am doing so voluntarily and that such information may be necessary to identify my records.

By checking this box, I acknowledge that I have read and agree to the above authorization. *