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 Form

RequiredWhat 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

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)

RequiredDoes this issue involve a Housing Authority in your area?

RequiredIf so, which one?

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.

**For Citizenship and Immigration Matters please download and fill out the USCIS Privacy Release Form at https://www.uscis.gov/sites/default/files/document/privacy-releases/USCIS-OLA-Privacy-Release-12-11-2017.pdf, then come back and upload it in the attachment section provided below.

Petitioner Information

*The "Petitioner" is the individual or company sponsoring the immigrant abroad. If you filed an I-130 or I-140, please input information about the U.S.-based person or company. If you self-petitioned, you may input information about yourself.

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.

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)

**If applicable to your case, please be sure to include a copy of your DD214 form with is request. You may upload it in the attachment section provided at the bottom of this form.

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)

Assistance with 2025 tax returns/refunds begins on March 15, 2026.

ATTENTION!

The IRS has advised a six month processing time for new or amended returns filed by mail and 21 days for returns e-filed. Please check the status of your refund using Where's My Refund?, the IRS2Go app, or their IRS Individual Online Account.

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

RequiredType of assistance needed:

**If applicable to your case, please be sure to include a copy of your DD214 form with is request. You may upload it in the attachment section provided at the bottom of this form.

RequiredBranch of Service

Are You A Veteran?

RequiredYour relationship to the veteran:

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

RequiredVeteran's Social Security Number:

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:

Veteran's Claim Initial File Date

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)

Social Security Number

Case Information

Claim # Type

Type of claim # you are providing

Claim #

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

In order to prevent delays in processing your request, please provide copies of the signed Tax Return or Amended Return for the tax year for which you need assistance, if applicable to your case, in the attachment field provided above.

Does your issue involve one of the following?

Identity Theft
Identity Theft (Business)
Trace My Refund (Must be six weeks since refund should have been received)

For identity theft-related issues, please download and fill out the Identity Theft Affidavit (Form 14039) at https://www.irs.gov/pub/irs-pdf/f14039.pdf, then come back and upload it in the attachment section provided above.

For identity theft (business)-related issues, please download and fill out the Identity Theft Affidavit (Form 14039) at https://www.irs.gov/pub/irs-pdf/f14039.pdf, then come back and upload it in the attachment section provided above.

For Trace My Refund-related issues, please download and fill out the Taxpayer Statement Regarding Refund (Form 3911) at https://www.irs.gov/pub/irs-pdf/f3911.pdf, then come back and upload it in the attachment section provided above.

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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