District 11 Constituent Services Request Form
✅ Our office CAN:
📞 Help you communicate with state agencies or submit an inquiry on your behalf.
📧 Request information, a status report, consideration or reconsideration on your case.
📝 Assist with applying for benefits, such as NJ FamilyCare or the Homestead Rebate.

❌ Our office CANNOT:
🚫 Force a state agency to act in your favor or speed up your case.
🚫 Overturn or influence matters involving private businesses.
🚫 Intervene with judicial issues, provide legal advice or recommend an attorney.
🚫 Legally get involved with pending litigation, including questions about criminal trials or imprisonment, child custody issues, and civil lawsuits.
🚫 Overturn or in any way influence a court’s decision.
Are you a resident of the 11th Legislative District? If not, we will be unable to assist you with any problem you may be facing, and encourage you to reach out to your own state representatives, who you can find at njleg.state.nj.us/members/legsearch.asp. You are a resident of the 11th Legislative District if you live in any of the following Monmouth County towns: Allenhurst, Asbury Park, Colts Neck, Deal, Eatontown, Freehold Borough, Freehold Township, Interlaken, Loch Arbour, Long Branch, Neptune City, Neptune Township, Ocean Township, Red Bank, Shrewsbury Borough, Shrewsbury Township, Tinton Falls, and West Long Branch. *
Required
First Name *
Last Name *
Phone Number *
Email Address
Preferred Means of Communication *
Town of Residence *
Zip Code *
Please list the names of any of our staff who you have previously worked with or spoken with. If you have previously spoken with a member of our staff but do not remember their name, you may leave this section blank.
Please briefly (in 1-2 paragraphs) describe the issue you are facing. *
Please write your full legal name below to signify that you understand that (1) this information may be passed on to a member of our Constituent Services staff for review, and (2) a member of our staff will attempt to reach out to you within 10 days of this request to discuss your case. *
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