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Constituent Service Form
Date constituent presented issue:
Information about constituent:
Home Address
Zip Code
Business Address (if applicable)
Zip Code
Important data if needed:
Home Telephone
Business Telephone
Social Security No.
Driver’s License No.
Spouse’s Name
State agency (if applicable):
Case No.
Claim No.
Description of constituent’s issue:
Other agencies contacted by constituent and their responses:
Actions taken by this office (dates, names, phone numbers of contacts; information/results obtained):
Date and method of response to constituent:
Was constituent’s issue successfully resolved?
For additional copies of this form, contact:
222 S. College, Suite 301
Springfield, Illinois 62704-1894
(217) 782-6851
Or print them from our Website: