Casework Privacy Release – DotGov Casework

Request for Assistance

Agency*

I request assistance in resolving the problem with the following agency (please select one):

Agency (Other)*

If you filed a petition for yourself, please enter your information in both the Petitioner/Applicant and Beneficiary sections.

Petitioner / Applicant

Name*

First Last

Date of Birth*

Country of Birth*

Alien Number (if any)

Beneficiary:

Name*

First Last

Date of Birth*

Country of Birth*

Alien Number (if any)

USCIS Information

USCIS receipt number or tracking number (no Social Security numbers)

Form Type(s) - Check all that apply:

Form type(s) - (if other)

Date of Filing

Place of Filing

Information about your issue

Date of Birth*

Place of Birth

Social Security Number

Mortgage Loan Number (if applicable)

Case Claim Number (if applicable)

Specific period or tax year(s) for which you are requesting assistance with the IRS. (if applicable)

In the field below clearly and thoroughly explain your postal delivery issue. Include the length of time this problem has existed with specific dates if available, the types of pieces you are missing or are delayed, and tracking numbers of packages you are missing. Please also include any attempts you have made to contact your post office and their response.

If applicable, please indicate which Veterans Administration hospital/clinic is involved in this casework assistance request in the field below.

Briefly explain your problem*

Clearly and thoroughly explain your problem, including dates, locations, names, and the specific remedy that you are seeking.

Supporting Documents

Please upload copies of supporting document(s), if necessary. The total size of uploaded files (combined) cannot exceed 8MB.

Drop files here or

Information about you

Prefix

Name*

First Middle Last Suffix

Your Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

eNewsletter Opt-in

Would you like to opt-in to the eNewsletter?

Constituent Authorization*

Under the Federal Privacy Act of 1974, we must have a signed privacy release form that clearly outlines your problem and the remedy you are seeking. This digital form provides our office permission to look into the matter on your behalf. Please make sure to attach any relevant identifying information and supporting documents which relate to your inquiry.

I hereby request the assistance of my representative in Congress to resolve the matter described below. I authorize my congressional representative and relevant staff to receive any information that they might need to provide this assistance. Under penalty of perjury, the information I have provided to my congressional representative is true and accurate to the best of my knowledge and belief. The assistance I have requested herein is in no way an attempt to evade or violate any federal, state, or local law.

Constituent Authorization*

Under the Federal Privacy Act of 1974, we must have a signed privacy release form that clearly outlines your problem and the remedy you are seeking. This digital form provides our office permission to look into the matter on your behalf. Please make sure to attach any relevant identifying information and supporting documents which relate to your inquiry.

I hereby request the assistance of my representative in Congress to resolve the matter described below. I authorize my congressional representative and relevant staff to receive any information that they might need to provide this assistance. Under penalty of perjury, the information I have provided to my congressional representative is true and accurate to the best of my knowledge and belief. In addition, I authorize the VA to discuss any conditions, actions and other information associated with ANY past and present VA claims/VA appeals and/or related to my VA healthcare. The assistance I have requested herein is in no way an attempt to evade or violate any federal, state, or local law.

Section below to be completed by the person who is the subject of the records:

I certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy release and any document submitted with it; 2) I reviewed and understand all of the information contained in my privacy release and submitted with it; and, 3) all of this information is complete, true, and correct. I authorize USDHS/USCIS/USDOS to release information contained in my USDHS/USCIS/USDOS records relevant to checking my case status to the extent permitted by law to my Member of Congress and relevant staff. I understand that I am not required to make payment in any form for the services provide by my Member of Congress.

Signature*

First Last

Please type in your name above to permit information from your file to be given to any agency deemed necessary. The Privacy Act of 1974 (PL 93-579) requires that you authorize access to your private records. Without your authorization, an inquiry on your behalf will not be possible.

Date*

MOC CRM Email

Assistance Request & Privacy Release Form

Please provide your contact information and briefly explain your request for assistance. Please attach any supporting documents and sign the privacy release authorization. (An asterisk (*) indicates required information.)

(Para obtener asistencia en español, presione el botón de lenguaje en la parte superior derecha de la página.)

Request for Assistance

Petitioner / Applicant

Beneficiary:

USCIS Information

Information about your issue

Information about you

Assistance Request & Privacy Release Form

Please provide your contact information and briefly explain your request for assistance. Please attach any supporting documents and sign the privacy release authorization. (An asterisk (*) indicates required information.)

(Para obtener asistencia en español, presione el botón de lenguaje en la parte superior derecha de la página.)

Request for Assistance

Petitioner / Applicant

Beneficiary:

USCIS Information

Information about your issue

Information about you

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