Government Contact Form

Effective 28 September 2017, this form must be filled out and submitted by any government employee wishing to do business with or otherwise contact me. This requirement may be waived on a case-by-case basis, generally including ones I first contacted unless under duress. However, unless the employee has been notified of such a waiver, they are obligated to act as though the requirement is in force.

Failure to submit a completed form prior to contacting me will cause the employee incur the obligations described below, and, to the extent the employee is unable or unwilling to honor those obligations, will cause the government agency said employee is working for to incur the obligations on their behalf.

Fields marked * are required.
Instructions can be accessed by clicking on a field label.

Your Name:	*
Office Address:	*
	*
City:	*
State:	*
Zip/Postal Code:	*
Country:	*
	*	Mail Address Different From Office Address

Mailing Address:	*
	*
City:	*
State:	*
Zip/Postal Code:	*
Country:	*

Office Phone Number:	*
Extension:	*
Cell Phone Number:	*
Email Address:	*

Agency:	*
Your Agency ID:	*
Years of Service:	*

Your Supervisor:	*
Supervisor's Title:	*
Supervisor's Phone Number:	*
Extension:	*
Supervisor's Location:	*

Reason for Contact:	*
	*	This Is A "Tax" Matter
		You must upload proof of the contract I signed, in advance, clearly showing my signature signed by my hand on the document with its full text that states what I was agreeing to pay for, how much I was going to pay, and what the payment arrangements would be. Failure to supply this proper supporting documentation of such any such "tax" claim shall immediately render it null and void.
Contract I Signed:	*
		Only GIF, JPG, PNG or PDF files under 24MB are supported.

Home Address:	*
	*
City:	*
State:	*
Zip/Postal Code:	*
Country:	*
Home Phone Number:	*
Home Email Address:	*

SSN:	*
Mother's Maiden Name:	*

Mortage Holder:	*
Branch Location:	*
Bank Phone Number:	*
Extension:	*
Monthly Payment:	*
Current Valuation:	*
Equity:	*

Years to Retirement:	*
Pension Balance:	*


Validation Code:	*	(case sensitive!) Enter the code above to help alleviate SPAM

	*	My Statements Are True and Complete By checking this box and submitting this form, you are asserting, under penalty of perjury, that your statements and the information you are submitting are true and complete, and that you are accepting any and all terms, conditions and obligations associated with submission of this form, whether explicitly stated or implied, including conditions that may later be added.

Failure to submit this form prior to contacting me will incur an obligation to pay a consulting fee of two thousand five hundred dollars ($2,500.00) for the first incident on any given matter, plus an additional fee of one thousand two hundred fifty dollars ($1,250.00) for each related incident, payable at the time of the incident. If the fees are not paid within thirty (30) days, interest will be added to the bill at a rate of one and one half percent (1.5%) per month or the maximum allowed by law, whichever is lesser, of the total outstanding obligation, computed monthly on the anniversary of the first incident. In addition, a late fee of one hundred dollars ($100.00) will be assessed and added to the total bill for any payment that is more than thirty-five (35) days past due, additional late fees may be assessed on the monthly anniversary of any previous late fee.

If the uncovered contact causes me to spend any additional time on the matter beyond initially assessing the charges due, a consulting fee of two hundred fifty dollars ($250.00) per hour, in four (4) hour increments, will become due and payable immediately, subject to the same terms and conditions as for the per-incident consulting fees stated above.

All information entered on this form will be used as I see fit. (This supercedes any other privacy policy statement made elsewhere on this site.)

These terms and conditions may be updated from time to time, and will obligate any outstanding debtors in accordance with the updated terms. Any such changes will be posted on this page and take effect when they are posted.

Fred Koschara

Government Contact Form