Response

JIM JUSTICE
UNITED STATES SENATOR FOR
WEST VIRGINIA

PRIVACY RELEASE and CONSTITUENT INFORMATION FORM

The office of United States Senator Jim Justice is happy to help in your interactions with agencies and offices of the federal government. This service, often called “casework,” is available to all West Virginians and covers a variety of issues. The Senator's office inquires about pending cases from passport applications to Social Security and veterans’ benefits and other matters. While we can’t guarantee the outcome of your case, and his office cannot file, adjudicate, or appeal your case, we will work to ensure the federal government is responsive to your concerns and your rights are respected.

Under Senate ethics rules, Senator Justice cannot assist in judicial or legal matters, including child custody/support disputes, divorces, criminal trials, lawsuits, or imprisonment matters. Additionally, as a United States Senator, he has no jurisdiction over state issues such as:

Medicaid
State taxes
Domestic disagreements/disputes
State criminal justice/court decisions

Residents of the State of West Virginia can contact Senator Justice’s office for assistance in dealing with federal agencies. If you have questions or concerns, please feel free to contact one of the state offices and a member of Senator Justice’s staff will assist you.

Please note this form should be filled out by the person needing assistance. If you have any issues completing this form online, please contact the Senator's Charleston Office at (304) 342-5855.

Pursuant to Public Law 93-579, the Privacy Act, I (i.e., the constituent) hereby authorize Senator Jim Justice 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.

Do you currently have a court case or other ongoing legal proceeding in regard to this matter?

Under Senate Ethics rules, Senator Justice's office cannot assist with a legal case or provide legal advice and in such cases recommends consulting with an attorney, if appropriate.

Your Name and Address

Prefix

First Name

Last Name

Date of Birth

Address Line 1

Address Line 2

City

State

Zip

Phone

Alternate Phone

Has another Congressional or Senate office been contacted to assist you regarding this issue? Yes
No

Duplicating inquiries through multiple offices could slow down the process of the Federal Agency responding to or working on your case. The office you contacted first will be the primary office assisting on your case.

If you answered yes, please list the office:

When did you contact them?

Briefly explain the problem. Attach copies of any relevant documentation in the attachment area provided below.

Attach copies of any relevant documentation here. ***Allowed file types: .doc, .docx, .jpg, .png, or .pdf***

You may upload multiple attachments, however there is a cumulative maximum file size limit = 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 issue

Social Security Number

Name of Federal Agency involved with issue:

If other, please specify agency

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

Which agency do you need assistance with?

If other, please specify:

CONSENT TO DISCLOSE RETURNS AND RETURN INFORMATION

Pursuant to 26 U.S.C. § 6103 (c), I

, an

[Company/Organization Name]

, authorize the disclosure of returns and return information relating to the liability of

for tax under 26 U.S.C. § 4181/Chapter 53 to Senator Justice and his staff. Such disclosure shall be limited to a period of

[days/months]

and shall be for the purpose of obtaining the Senator's assistance in in obtaining information concerning:

Executed this

day of

Inmate Number:

Healthcare Issue Type (Choose one)

Marketplace ID Number

Name of Plan you are enrolled in

Claim Number

For assistance with Tricare, please download and fill out the DD form 2870, then come back to this page and upload it in the attachment section provided above.

Visit https://www.justice.senate.gov/wp-content/uploads/2025/03/DD2870-Military-Authorization-for-Disclosure-of-Medical-or-Dental-Information.pdf.

On whose behalf are you submitting this privacy release form?

If other, please specify

Petitioner/Applicant

Full Name

Date of Birth

Alien Number

Country of Birth

Beneficiary

Full Name

Date of Birth

Alien Number

Country of Birth

USCIS receipt number or tracking number

Date of Filing

If other, please specify

Section below to be completed by the person who is the subject of the records:

I certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy release and any document submitted with it; 2) I reviewed and understand all of the information contained in my privacy release and submitted with it; and 3) all of this information is complete, true, and correct.

I, [YOUR NAME HERE], 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 Jim Justice and the Member's staff.

Return Type

Full Name

Taxpayer Identification Number

Spouse's Full Name

Spouse's Taxpayer Identification Number

Form Number

Tax Year(s) or Period(s)

Please attach copies of any letters you received from the IRS or copies of tax forms in the attachment section provided above.

Labor and Unemployment Issue Type

Claim or Case Number

Military Issue Type (Choose one)

Reference Number

Attention!! For assistance with Tricare, please download and fill out the DD form 2870, then come back to this page and upload it in the attachment section provided above.

Visit https://www.justice.senate.gov/wp-content/uploads/2025/03/DD2870-Military-Authorization-for-Disclosure-of-Medical-or-Dental-Information.pdf.

CSA or CSF Number of Annuitant

SSN of Annuitant

Date of Retirement

Employing Agency

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

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

Expedite fee paid?

Overnight delivery fee paid?

Passport Application Locator Number

Application Date

Travel Date

Destination

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

Small Business Issue Type

Application or Loan Number

Date of Application

Name of Lender

Date of Application for Forgiveness

Current Level of Claim

Who are you seeking assistance for?

First Name of Applicant

Middle Name of Applicant

Last Name of Applicant

Date of Birth of Applicant

Social Security Number of Applicant

Type of help you are seeking

Are you a veteran?

Veteran's Name

Are you the widow or widower of a combat veteran?

Veteran's Date of Birth

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 #

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 Jim Justice and/or his staff for the purpose of __________.

Today's Date

This signature must be from an individual who is 18 years of age or older and is requesting assistance or has a pending case with a federal agency. Third party signatures, including those of immediate family members, are not acceptable. Federal agencies will not release information without the signed consent of the proper individual.

Sign using your mouse or finger...