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Congressman David Scott Media Authorization Form (GA-13)
The Privacy Act of 1974 prohibits the federal government from releasing any information from personal files of individuals without the express written permission of the person involved.  Disclosure of personal records to a Congressman acting on behalf of a constituent is prohibited, unless the individual to whom the record pertains has consented.

Your private information is confidential, by submitting this form you confirm that you authorize the office to use the receipts of your casework success as an example for media purposes that are included but not limited to social media sites, newsletters, and websites.
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Email *
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First Name *
Last Name *
Phone Number
Hometown *
Our office has reached out to a federal agency on your behalf. Please let us know how we did.
Congressman Scott is committed to serving the constituents of Georgia's 13th Congressional District and would appreciate being able to share some of your stories in constituent communications and on social media.  Do you agree to allow Congressman Scott to share a quotation provided by you or your feedback from this form? * *
I certify that I am a resident of Georgia's 13th Congressional District and have not been compensated for this testimony * *
How satisfied were you with the caseworker who assisted you? *
Was your case resolved? *
How long did it take? *
Please provide 1-3 sentences on your experience working with Congressman David Scott's Office. *
A copy of your responses will be emailed to the address you provided.
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