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Senador Taylor Rehmet, District 9 Casework

CASEWORK INTAKE FORM

Please first review our casework policies and guide (PDF format)

You do not need to fill out the form in this PDF, unless you’d like to do so instead of the web form below.

I hereby request and authorize State Senator Taylor Rehmet, or representative, to review all appropriate documentation deemed necessary in connection with any action involving the state agency named below or application for assistance. I understand that any documents provided to Senator Rehmet, or his staff, may be copied, forwarded, or saved in order to share with the state agency for review. By signing this form, I attest to have read and understood the Senate District 9 guide provided to me with this form. Additionally, I understand completion of this form does not guarantee a favorable outcome.

Fields marked with an asterisk * are required.

Name: *

Date of Birth: *

Gender: *

Address: *

Apartment/Unit #

City: *

State: *

Zip Code: *

Phone: *

E-mail: *

APPLICABLE IDENTIFIABLE INFORMATION
(if available; not required)

Agency(s) Involved:
Veterans Claim Number:
License Plate Number:
Driver's License Number:
Military ID and Branch:
Case Number:
Claim Number:
Other:
(e.g. Any applicable tracking, reference, confirmation, application, permit, license, or ID numbers)

CASE DETAILS

Briefly describe the nature of assistance you are requesting. *
Please keep information pertinent to the case.

By checking this box and submitting this form, I attest that I have read, understand, and agree to the above terms. * I agree