Select your zip code to continue * - Select - 91752 92324 92373 92501 92502 92503 92504 92505 92506 92507 92508 92509 92518 92530 92551 92553 92555 92557 92570 92571 92860 92878 92879 92880 92881 92882 92883 Name / Nombre * Address / Dirección * City / Ciudad * Zip code / Código postal * Phone / Numero de Teléfono * Email / Correo Electrónico * Agency * - Select -Employment Development Department (EDD)Department of Motor Vehicles (DMV)Franchise Tax Board (FTB)Riverside County DPSS (Medi-Cal, CalFresh, CalWorks, IHSS)Other State Agency or State-Related Program Describe the Issue / Describa el problema * REQUEST FOR ASSISTANCE AND AUTHORIZATION FOR RELEASE OF INFORMATION Please carefully read the following: By completing this form, I am requesting the Office of State Senator Roth (the “Senator”) to assist me in working with the agency listed above. I acknowledge that this may require the release of information contained in my records the dissemination of which may be prohibited by law. Therefore, I hereby authorize the agency listed above and the Senator to share all relevant portions of my records with each other, and to discuss matters relating to those records and my claim, until my claim is resolved. I agree that I will not submit any personal identifiable information through this form that is not specifically requested. If the Senator’s office needs additional information, the office will contact me to request that information. By clicking here, I accept and agree to the terms in this form. Agreement * Leave this field blank Submit
