Directions: print this form, complete it, and fax it to (609) 530-3292 or mail it to the address listed at
the bottom of the form.
Date:__________________________
Dear Senator Turner,
I would like to request assistance with the following problem I am having with the agency listed
below.
I am authorizing you and/or your staff to request information on me, which would be required in
your investigation of the matter, outlined below.
Please Print or Type:
Name___________________________________________________________
Address_________________________________________________________
City_________________________________ ZIP_____________________
Home Phone____________________ Work Phone____________________
Email Address:_________________________________________________
Social Security#________________________________________________
Other Identifying #:_____________________________________________
Signature______________________________________________________
Briefly explain the nature of your complaint or concern and attach copies of any documents you
may have.
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What steps have you taken so far? If possible, please include name of agency or persons you have
contacted.
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What has been the results of your efforts to date?
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What would you consider a fair outcome?
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Thank you.
Please return this form to:
Senator Shirley K. Turner
1440 Pennington Road
Trenton, NJ 08618