Response

Privacy Release Form

My office is happy to help you in your interactions with the agencies and offices of the federal government. Casework is available to all North Dakotans and covers a variety of issues, from helping with passport applications to answering questions about social security or veterans benefits. While we can't guarantee the outcome of your case, we'll work to ensure that the federal government is responsive to your concerns and that your rights are respected.

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

1. County Social Services

2. Medicaid

3. State taxes

4. State unemployment

5. State worker's compensation

The North Dakota State Government website may have helpful information if you're addressing a state issue.

If you have questions or concerns, please feel free to contact one of my state offices.

Petitioner/Applicant

Prefix

First Name

Middle

Last Name

Address Line 1

Address Line 2

City

State

Zip

Home Phone

Cell Phone

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

Have you contacted another Congressional office regarding this matter?

Yes

Which office?

When? (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

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

Yes

Designee Contact Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

While Medicaid is federally funded, North Dakota state officials are in charge of the administration of this program. Please call 701-328-7068 or 1-800-755-2604, or visit their website at http://www.nd.gov/dhs/ with questions/issues/comments concerning the Medicaid program.

Healthcare Issue Type (Choose one)

If your issue involves an unemployment claim or worker's compensation issue with an employer other than the federal government, your claim would fall under the purview of the state of North Dakota. Unemployment issues should be directed to North Dakota Job Service, which may be reached by calling 701-328-2825 or on the web at https://www.jobsnd.com. Worker's compensation questions should be directed to the North Dakota Workforce Safety & Insurance agency, which may be reached by calling 1-800-777-5033 or on the web at https://www.workforcesafety.com.

Labor and Unemployment Issue Type

If your issue involves your student loan processed through the Bank of North Dakota, questions should be directed to them at 833-397-0311.

Student Loan Issue Type

Military Case Type

Veteran Case Type

Marketplace ID Number

Name of Plan you are enrolled in

Which Government Agency (or Agencies) have you been working with?

Claim Number (if available)

Please Select one of the following

Citizenship

Immigration

Related Matter

Visa

First Name of Applicant

Middle Name of Applicant

Last Name of Applicant

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

Gender of Applicant

Country of Origin of Applicant

Applicant Alien Registration #

First Name of Beneficiary

Middle Name of Beneficiary

Last Name of Beneficiary

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

Gender of Beneficiary

Country of Origin of Beneficiary

Beneficiary Alien Registration #

USCIS Receipt Number

Date when you applied (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

Date of Interview (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

Name of Attorney

Phone Number of Attorney

USCIS Form Type

If other (form), please specify

Underlying Petition?

Type of Visa

U.S. Embassy or Consulate Abroad

Reason for travel to the United States

Has applicant ever applied for an immigrant visa, green card or citizenship?

Has applicant ever been previously denied a visa to the United States?

Which Government agency have you been working with?

Department of Labor	Equal Employment Opportunity Commission	Federal Workers' Compensation	Job Service North Dakota
National Labor Relations Board	ND Workers' Compensation	Office of Personnel Management	Other

If other, please specify

Claim or Case Number

If other, please specify

Reference #

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)

Date of Service (From) (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

Date of Service (To) (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

VA Claim #

Home State of Record

Working with a Veterans Service Organization (VSO)?

Do you have a copy of your discharge papers?

The Department of State is experiencing significant delays in processing passport applications. More information can be found at https://travel.state.gov/. IF YOU ARE TRAVELING IN THE NEXT 7 DAYS, PLEASE CALL 701-250-4618 FOR IMMEDIATE ASSISTANCE.

First Name of Applicant (Exactly as stated on passport application)

Middle Name of Applicant (Exactly as stated on passport application)

Last Name of Applicant (Exactly as stated on passport application)

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

Date when you applied for U.S. passport (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

Date of Travel (Use mm/dd/yyyy format, then press "Tab" button on keyboard)

Did you pay for expedited service?

Passport Locator #

*PLEASE UPLOAD PROOF OF TRAVEL IN THE ATTACHMENT SECTION BELOW.*

Please acknowledge that you have uploaded your proof of travel in the attachment section on the bottom of this form.

First Name of Applicant

Middle Name of Applicant

Last Name of Applicant

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

Gender of Applicant

Agency Case #

Social Security Number (If applicable)

Description of Request

Do you grant Senator Hoeven's office permission to contact other congressional offices to your inquiry?

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

I hereby certify, under penalty of perjury, that (1) I provide and authorize this information, (2) I reviewed and understand the provided information, and (3) that all the information is complete, true and correct. I provide and authorize the information and documents to be received and reviewed by Senator Hoeven and his staff, and authorize this request/information to be forwarded to any federal agency for further review on my behalf. I also authorize the receipt of information from any federal agency, to the office of Senator Hoeven, relevant to the matter described.

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