Share Your Casework Successes

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Thank you for trusting our office to assist with your federal agency matter. We appreciate the opportunity to work with you! To help promote the important work that our constituent services team offers, we would love to share your successful case resolution.

We'd appreciate your willingness to contribute by sharing your experience working with our office toward resolution of your case.

Please note that full names and other sensitive information regarding your case will be excluded from all distributed materials.

If you would like to participate, please submit a brief written testimonial using the form below. You can include any information, including: the issue that you brought to our office, your experience working with our staff, the resolution reached, and the lasting effects of resolving the case. If you have any questions or concerns, please don't hesitate to call our office at 202-225-2661.

We hope that you will join us in sharing ways that our office can assist other individuals in the community!

Your Information

Prefix:

First Name:

MI:

Last Name:

Suffix:

Your Contact Information

Address

Address 2

City/Town

State

ZIP Code

Email:

Telephone

Phone Number

Phone Type:

What are these options?

Constituents who are hard of hearing or use a video phone have the option to choose TDD or VP based on the type of device they are using. This allows our office to respond to them accordingly. The default option 'Voice' is a standard audible telephone.

Case Information

Agency Involved:

Caseworker's Name:

Your Testimonial

Please describe the original issue:

Please describe your experience with our office:

Would you be willing to discuss your experience with the Congresswoman in person or via virtual meeting?

Yes

Media Release Authorization

Please Read the Following Notice and Check One of the Options Below:

I grant permission to the Office of Congresswoman Lateefah Simon, hereinafter known as the "Office" to use my first name, city, testimonial or image (photographs and/or video) for use in the Office's publications, including but not limited to: video; social media; press release; mass mailing; newsletter; electronic newsletter; and website. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any request for compensation in relation to the use of the image. I acknowledge that the Office owns all rights to the testimonials, images and recordings. I hereby release, defend, indemnify and hold harmless the Office from and against any claims, damages or liability arising from or related to the use of the images, recordings or materials, including but not limited to claims of defamation, invasion of privacy, or rights of publicity or copyright infringement, or any misuse, distortion, blurring, alteration, optical illusion or use in composite form that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

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