The Privacy Act of 1974 prohibits the disclosure of personal information without the individual’s written consent. In order for the Senator’s office to open a case on your behalf, please complete this form and return it to one of her offices located in Illinois. Please include copies of any relevant documents.
Privacy Act Release From
All Names Associated With The Account
Please download and fill out ICE's Immigration and Customs Enforcement Privacy Waiver at https://www.ice.gov/file-download/download/public/80509, then upload it in the attachment section provided below.
For health care-related issues, please download and fill out an Authorization for Disclosure of Medical or Dental Information at https://www.esd.whs.mil/Portals/54/Documents/DD/forms/dd/dd2870.pdf, then come back and upload it in the attachment section provided below.
Please provide your proof of travel in the attachment section provided below!
ATTENTION!The IRS has advised a six month processing time for new or amended returns filed by mail.Case Information
Attach copies of any relevant documents or notices here. Allowed file types include .doc, .docx, .jpeg, .pdf, or .txt. Total file size limit is 15MB.
I am aware that provisions of the Privacy Act of 1974 (Public Law 93-579) may prohibit the release of information in covered agency files without any consent. I hereby give my consent for any applicable federal agency (ies) to release such information to the Office of United States Senator Tammy Duckworth and/or members of her staff in connection with my case or claim.