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Senador Nathan Johnson, District 16 Casework

CASEWORK REQUEST FORM

I hereby request and grant authorization for State Senator Nathan M. Johnson to intercede on my behalf, including the authority to review all relevant documentation deemed necessary by him or his staff in connection with an application for assistance or any other matter pending with a Texas state agency. I acknowledge that any documents I provide may be copied and transmitted to officials of the appropriate state agency for purposes of review.

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

Fields marked with an asterisk * are required.

Name: *

E-mail: *

Address: *

Apartment/Unit #

City: *

State: *

Zip Code: *

Date of Birth:

Phone: *

Do you have a lawyer, or have you received legal counsel regarding this matter? YES
NO

Have you contacted other Legislative offices for assistance with this matter? YES
NO

Please provide any applicable identifying information:

Agency Involved:
Other:
(e.g. Any applicable tracking, reference, confirmation, application, permit, license, or ID numbers)
Military Branch:
Case Number:
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Briefly describe the nature of the assistance you are requesting: