Response

1015 N. Broadway Ave., Suite 310 • Oklahoma City, OK 73102 • Phone: (405) 231-4941 • Fax: (405) 231-5051

Mid-Continent Tower• 401 S. Boston Ave., Suite 2150 • Tulsa, OK 74103 • Phone: (918) 581-7651 • Fax: (918) 581-6332

PRIVACY RELEASE and CONSTITUENT INFORMATION FORM

The office of US Senator James Lankford is happy to help in your interactions with agencies and offices of the federal government. Casework is available to all Oklahomans and covers a variety of issues. The Senator's office inquires about pending cases from passport applications to Social Security and veterans’ benefits. While his office cannot file, adjudicate, or appeal your case, we will work to ensure the federal government is responsive to your concerns.

Due to the Constitution’s separation of powers, Senator Lankford cannot assist in judicial or court matters, including child custody/support, divorce, criminal trials, lawsuits or imprisonment. Additionally as a United States Senator, he has no jurisdiction over state issues such as:

County social services
Medicaid
State taxes
State unemployment
State workers' compensation
Domestic disagreements/disputes
Criminal justice/court decisions

Pursuant to Public Law 93-579, the Privacy Act, I (i.e., the constituent) hereby authorize Senator James Lankford and/or his staff to request and receive information from the appropriate federal agency or department in reference to my inquiry. This authorization includes written correspondence, telephonic, or any other means of communication. The federal agency or department is authorized to furnish copies of any documents, correspondence, or information relative to my inquiry until the matter is resolved.

Your Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Work Phone

Cell Phone

Date of Birth

Social Security Number (If applicable)

Has another Congressional or Senate office been contacted to assist you regarding this issue?

Yes

If yes, please list the office:

Would you like to designate someone with whom we may discuss the details of your case?

Yes

Designee's Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Would you like to designate a second person with whom we may discuss the details of your case?

Yes

Designee's Information (#2)

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Would you like to designate a third person with whom we may discuss the details of your case?

Yes

Designee's Information (#3)

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Would you like to designate a fourth person with whom we may discuss the details of your case?

Yes

Designee's Information (#4)

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Briefly explain the problem. Attach copies of any relevant documentation.

Attach copies of any relevant documentation.
***NOTE: ALL EMAILED DOCUMENTS MUST BE IN PDF FORMAT (i.e., NO PHOTOGRAPHS).*** Maximum file size = 15MB. You may send additional documentation directly to your caseworker after they have made contact with you.

Upload FileNo file chosen

If "Other", please specify:

Due to the Constitution's separation of powers, Senator Lankford cannot assist in judicial or court matters.

Agency Name:

ATF (please contact the office for an additional required form)

Federal Bureau of Prisons

Other

If "Other", please specify:

While Medicaid is federally funded, Oklahoma state officials are in charge of the administration of this program. Please contact the Oklahoma Health Care Authority, the Oklahoma Department of Human Services, and/or your local state representative or state senator for assistance.

Healthcare Issue Type (Choose one)

Petitioner's Name

Petitioner's Country & Date of Birth

Petitioner's Alien Number

Beneficiary's Name

Beneficiary's Country & Date of Birth

Beneficiary's Alien Number

Application Type(s)

Receipt(s) #

Application Date

For IRS Inquiries, you MUST provide a complete, signed copy of your tax return. You may upload it in the space provided above.

Company Name (if applicable)

EIN # (if applicable)

Type of Tax

Tax Year From

Tax Year To

How did you file your return?

Tax Form

Date Filed

Do you give Taxpayer Advocate Service permission to contact the you directly regarding this inquiry?

If your issue involves an unemployment claim or workers' compensation issue with an employer other than the federal government, your claim would fall under the purview of the state of Oklahoma. Please contact the necessary state agency or your local state representative or state senator.

Labor and Unemployment Issue Type

Which Government agency have you been working with?

Department of Labor	Equal Employment Opportunity Commission
Federal Office of Workers' Compensation	National Labor Relations Board
Other

CSA or CSF Number of Annuitant

SSN of Annuitant

Date of Retirement

Employing Agency

Applicant or Number Holder Information

Current Level of Claim

First Name

Middle Name

Last Name

Date of Birth

Military Case Type

Reference #

Veteran Case Type

Are you a veteran?

Veteran's Name

Are you the widow or widower of a combat veteran?

Veteran's Date of Birth (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

Dates of Service

VA Claim #

Duty Station

Working with a Veterans Service Organization (VSO)?

Do you have a copy of your discharge papers?

VA Case/C-File #

Small Business Issue Type

Application or Loan Number

Date of Application

Name of Lender

Date of Application for Forgiveness

If other, please specify.

Federal Employing Agency

Claim Number

Date of Injury

Name of Treating Physician(s)

*ATTENTION!* If you need assistance with a passport issue please provide your social security number (in the field above: "Social Security Number (If applicable)" ) AND upload a copy of your travel itinerary (in the attachment section above: "Attach copies of any relevant documentation.").

*Failure to provide all requested information and documents will result in significant delays in processing.

Expedite fee paid?

Overnight delivery fee paid

Locator #

Application Date

Travel Date

Destination

Branch of Service

Rank/Grade

Are you working with a patient advocate/service officer? If so, who?

Pursuant to 38 USC 7332 and 45 CFR 164.524, I hereby authorize

...to release

...to Senator James Lankford and/or his staff for the purpose of

Have you provided your social security number and itinerary in the fields above?

Today's Date

Sign using your mouse or finger...