Help With a Federal Agency

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

What can I assist you with?

Your Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone Number

Alternate Phone Number

Date of Birth

Please select your County

Have you contacted another Congressional office regarding this matter?

Which Office?

When?

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

Their relationship to you:

Designee's Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Loan/Claim Number

Bank/Lender Name

Description of Request (Max 150 Words)

Marketplace ID Number

Name of Plan you are enrolled in

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

Claim Number (if available):

Description of Request (Max 150 Words)

Have you contacted a HUD-approved counseling agency, nonprofit or other third party?

Name of Agency

Other Agency

When Did You Contact the Agency?

Other Agency/Attorney

Did you pay a fee?

Name of Lender/Servicer:

Loan Number:

Are you in a foreclosure?

Date of Foreclosure

Are you in a court remediation?

Are you seeking a mortgage modification?

Have you contacted any state agencies?

State Agency you have been working with:

Name of Investor Loan:

Associated Account Number:

All Names Associated With The Account

First Name

Last Name

Date of Birth

Add Another?

First Name

Last Name

Date of Birth

Add Another?

First Name

Last Name

Date of Birth

Description of Request (Max 150 Words)

Please Select one of the following:

Petitioner Information

First Name of Petitioner

Middle Name of Petitioner

Last Name of Petitioner

Date of Birth of Petitioner

Gender of Petitioner

Country of Origin of Petitioner

Case Information

USCIS Receipt Number

Date when you applied:

Date of Interview:

Description of Request (Max 150 Words)

I, ___________________, authorize USCIS to release information contained in my USCIS records as relevant to checking my case status, and to the extent permitted by law, to Senator Tammy Duckworth and her staff.

Petitioner Information

First Name of Petitioner

Middle Name of Petitioner

Last Name of Petitioner

Date of Birth of Petitioner

Gender of Petitioner

Country of Origin of Petitioner

Alien Number of Petitioner

Case Information

USCIS Form Type:

USCIS Receipt Number

Underlying Petition?

Date when you applied

Date of Interview

Description of Request (Max 150 Words)

Petitioner Information

First Name of Petitioner

Middle Name of Petitioner

Last Name of Petitioner

Date of Birth of Petitioner

Gender of Petitioner

Country of Origin of Petitioner

Passport Number of Petitioner

Case Information

CEAC Case Number

U.S. Embassy or Consulate Abroad

Reason for travel to the United States (Max 150 Words)

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

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

Description of Request (Max 150 Words)

I, ___________________,

authorize the _____________________

to release information contained in my _____________ records as relevant to checking my case status, and to the extent permitted by law, to Senator Tammy Duckworth and her staff.

Description of Request (Max 150 Words)

Is this regarding a deportation?

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.

Which Government agency have you been working with?

Please Specify

Claim or Social Security Number

Description of Request (Max 150 Words)

Subscriber Information

First Name of Subscriber

Middle Name of Subscriber

Last Name of Subscriber

Date of Birth of Subscriber

Social Security Number of Subscriber

Gender of Subscriber

Member ID Number

Case Information

Description of Request (Max 150 Words)

Case Information

Are you active duty?

Date of Birth of Veteran

Veteran's Name:

Date of Service:

Home State of Record

Working with a Veterans Service Organization (VSO)?

VSO Representative's Name

VSO Representative's Phone Number

Do you have a copy of your discharge papers?

Branch of Service

Is this issue related to your health care?

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.

Description of Request (Max 150 Words)

Applicant Information

First Name of Applicant

Middle Name of Applicant

Last Name of Applicant

Date of Birth of Applicant

Social Security Number of Applicant

Gender of Applicant

Country of Origin of Applicant

Case Information

Date when you applied for U.S. passport

Date of Travel

Passport Application Number:

Description of Request (Max 150 Words)

Please provide your proof of travel in the attachment section provided below!

Applicant Information

First Name of Applicant

Middle Name of Applicant

Last Name of Applicant

Date of Birth of Applicant

Social Security Number of Applicant

Gender of Applicant

Case Information

Description of Request (Max 150 Words)

Social Security Number

Case Information

Student Loan Number

Lender Information

Description of Request (Max 150 Words)

ATTENTION!

The IRS has advised a six month processing time for new or amended returns filed by mail.

Case Information

Date of Birth

Social Security Number

Are you filing jointly?

Full Name of Joint Filer

Social Security Number or Tax ID Number of Joint Filer

Type of Return

Tax Year

Filing Method

Date of Filing

Tax ID Number(Only if different than SSN)

Description of Request (Max 150 Words)

Case Information

Tracking Number

Date Item Shipped

Date Item was to be Delivered

Location of relevant post office

Description of Request (Max 150 Words)

Case Information

Are You A Veteran?

Veteran's Name (if different from the individual submitting this request):

Are You the widow or widower of a combat veteran?

Date of Birth of Veteran

Date of Service: (From)

Date of Service: (To)

VA Claim Number:

Home State of Record

Working with a Veterans Service Organization (VSO)?

VSO Representative's Name

VSO Representative's Phone Number

Do you have a copy of your discharge papers?

Description of Request (Max 150 Words)

Case Information

Name of Agency

Are you seeking assistance with the Federal Bureau of Prisons?

Inmate Number

Reference #:

Description of Request (Max 150 Words)

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.

Upload FileNo file chosen

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.

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