Constituent Intake Form

Please visit Legmap.org and confirm you live in Rep. Vargas's District (Submissions from outside the district are automatically deleted - we will not see them)*

Yes, I am Rep. Vargas's constituent and live in his district

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth*

MonthDayYear

Email*

example@example.com

Issue Type*

Claimant ID

Please briefly describe what you are experiencing and any other information that may be helpful:*

Please upload any relevant files:

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Pursuant to the Privacy Act of 1974, our office cannot assist individuals without their express consent. I,Signature - Full Name* hereby authorize the Office of State Representative Andy X. Vargas to act on my behalf, and therefore, waive all rights in the release of any and all related information and records. I also understand that this inquiry may not conclude in my best interest. I sign this waiver in good conscience and without mental reservation.

Constituent Intake Form

Introduction