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| Name:__________________________________ |
Address:________________________________ |
Daytime Phone:__________________________ |
Evening Phone:___________________________ |
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Other Cases/ID Numbers: _______________________________________ |
Please include any other relevant identification numbers used by an agency:
(i.e. civil service, worker's compensation)
_______________________________________________________________________________________
Please write a statement concerning the specific information
you are requesting or the exact
nature of the problem you encountering. Please also indicate
if you are working with an attorney.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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Signature:_______________________________
Date:_____________________________
Please Return to:
Senator Richard Lugar
1180 Market Tower Building
10 West Market Street
Indianapolis, IN 46204-2964
317-226-5555