DEPORTATION CASE PRIVACY RELEASE FORM

If you are an individual in the midst of deportation proceedings or are a detainee in need of assistance, please complete the following form. Lawyers representing these individuals may also complete this form on their behalf.

Note that by completing this form, you are authorizing the U.S. Department of Homeland Security (DHS) to disclise information and/or records about you to Senator Klobuchar's office.

Detainee/Deportation Proceedings Respondent 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 Number

Date of Filing

Which federal agencies are involved with this issue?

Was this form filled out by the respondent/detainee's attorney?

Case Information

Application Type

Receipt Number

If other, please specify:

I would like to waive my right to confidentiality and authorize disclosure to the Senator Klobuchar's office regarding these immigration benefits:

Temporary Protected Status (TPS)
T Visa (for Trafficking Victims)
U Visa (for Victims of Certain Crimes)
Seasonal Agricultural Worker
Battered Spouse/Child
Violence Against Women Act
Asylum Seeking Hardship Waiver (VAWA)

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?

If so, which office(s)?

Are you working with an attorney on this issue?

Can our office contact your attorney?

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.

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By signing this form, you certify under penalty of perjury that the information above is accurate. You authorize DHS, its components, offices, employees, contractors, agents, and assignees, to disclose the information or records specified above to the office of Senator Klobuchar. You understand this may include and is not limited to reports, evaluations, and notes of any kind, contained in any record keeping system maintained by or on behalf of DHS; that DHS retains the discretion to decide if particular records or information are within the scope of this Waiver; and that DHS has no control over how Senator Klobuchar's office will use or disseminate my information. You agree to release and hold harmless DHS, its components, offices, employees, contractors, agents, and assignees, from any and all claims of action or damages of any kind arising from, or in any way connected to, the release or use of any information or records pursuant to this Waiver.

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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