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
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*
Date Format: MM slash DD slash YYYY
Country of Birth*
Alien Number (if any)
Beneficiary:
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
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:
- G-639
- I-90
- I-129
- I-29F
- I-130
- I-131
- I-140
- I-212
- I-290B
- I-360
- I-485
- I-526
- I-539
- I-589
- I-590
- I-600A
- I-600
- I-601
- I-612
- I-690
- I-730
- I-751
- I-765
- I-821
- I-824
- I-829
- I-914 (Supplement A, B, or C)
- I-918
- I-924
- I-929
- N-400
- N-600
- N-565
- N-644
- Other
Form type(s) - (if other)
Date of Filing
Date Format: MM slash DD slash YYYY
Place of Filing
Information about your issue
Date of Birth*
Date Format: MM slash DD slash YYYY
Place of Birth
Social Security Number (if applicable to case)
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)
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

Accepted file types: pdf, jpg, gif, png.
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*
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*
Date Format: MM slash DD slash YYYY
MOC CRM Email

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