Response

Personal Information

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Date of Birth

Phone

Work Phone

Cell Phone

Country of Birth

Alien Registration Number

Social Security Number - Do not provide SSN for immigration and housing issues

Case Information

What is the general topic of your request? Military and Veterans IssuesSocial Security
ImmigrationOther

ATTENTION: If you need help with a deportation related issue, please complete this form, but also have the the detainee/deportation proceedings respondent or their lawyer complete our office's Deportation Case Privacy Release Form. See note at the top of this form for clarification.

ATENCIÓN: Si necesita ayuda con un asunto relacionado con la deportación, completa este formulario, pero también pida al demandado del detenido/procedimiento de deportación o a su abogado que completa el Formulario de divulgación de privacidad del caso de deportación de nuestra oficina. Consulte la nota en la parte superior de este formulario para obtener una aclaración.

Which federal agencies are involved with this issue?

Are you submitting a request for military records? YesNo

Please fill out the following information so our office can submit an SF180 form on your behalf.

Veteran Name

Veteran SSN

Veteran Date of Birth

Veteran Place of Birth

Veteran Status Active
Reserve
State National Guard

Branch

Date Entered

Date Released

Was/is this individual an officer? YesNo

Was/is this individual enlisted? YesNo

Service Number

Branch

Date Entered

Date Released

Was/is this individual an officer? YesNo

Was/is this individual enlisted? YesNo

Service Number

Branch

Date Entered

Date Released

Was/is this individual an officer? YesNo

Was/is this individual enlisted? YesNo

Service Number

Is this individual deceased? YesNo

Date of Death

Did this individual retire from service? YesNo

Please select the items you would like to request:DD Form 214 or equivalent
Medical Records
Other

Year(s) in which DD Form 214 or equivalent was issued to the veteran:

Medical records you would like to request. If hospitalized, the facility name and date (month and year) for EACH admission must be provided.

Other items requested:

Please explain the purpose of your request:

Please note that by signing this form you certify under penalty of perjury under the laws of the United States of America that the above information entered above is true and correct and authorize the release of the requested information.

Is the individual currently serving? YesNo

Which agency is this issue concerning? Veterans Benefit Administration
Veterans Health Administration
Other

If other, please specify:

Type of claim filed

Type of social security claim filed

Initial Claim Status PendingApprovedDeniedNone

Reconsideration Status PendingApprovedDeniedNone

ALJ Hearing Status PendingApprovedDeniedNone

Appeals Council Status PendingApprovedDeniedNone

Beneficiary Information

*Please include detainee/deportation proceedings respondent information here if applicable.

Beneficiary First Name

Beneficiary Last Name

Beneficiary Email

Beneficiary Date of Birth

Beneficiary Country of Birth

Beneficiary Alien Number

Beneficiary Date of Filing

Other Immigration Information

Application Type

Receipt Number

Please provide a detailed account of your situation:

Please explain how Senator Klobuchar's office can assist you:

Have you contacted another office about this issue? YesNo

If so, which office(s)?

Are you working with an attorney on this issue? YesNo

Was this form filled out by the beneficiary's attorney? YesNo

Can our office contact your attorney? YesNo

Attorney Contact Info

First Name

Last Name

Work Phone

Please attach any files relevant to your case here. All attachments must be submitted in a PDF format.

Upload FileNo file chosen

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 submitted with it; and 3) all of this information is complete, true, and correct. I hereby authorize the office of U.S. Senator Amy Klobuchar to access my records and act on my behalf with any and all agencies necessary to resolve the matters listed above.

Date Signed

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