Constituent Intake Form

Constituent Intake Form

*PLEASE READ THE FOLLOWING CAREFULLY*
Introduction

Thank you for contacting the Office of State Representative Andy X. Vargas. We love hearing from our constituents! Our mission is to connect Haverhill residents to state resources, services and to assist them with navigating their state government. As such, this form is strictly for our constituents. All other submissions will automatically be deleted. Please DO NOT use this form to ask questions about legislation, policy or events. For those inquiries, please email Andy.Vargas@mahouse.gov. Please DO NOT submit this form more than once for the same issue - it will not speed up casework and may slow it down.
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*

Unemployment (DUA)Pandemic Unemployment (PUA)SNAP/"Food Stamps"MassHealth IssueRMV IssueCOVID-19 VaccinePaid Family and Medical LeaveHousing/HomelessnessOther
Claimant ID
Please briefly describe what you are experiencing and any other information that may be helpful:*
Please upload any relevant files:

Cancelof
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.
Should be Empty:

Constituent Intake Form

Introduction