Response

MIKE LEE
U.S. SENATOR for UTAH

CONSENT FOR RELEASE OF PERSONAL RECORDS

I am requesting that the office of Senator Mike Lee investigate a matter on my behalf. Any information and records that may be of assistance to Senator Lee and his staff in resolving this problem may be released to them, including information and records which are protected by privacy laws. I understand that this form is being used in accordance with the Privacy Act of 1974.

Is this an immigration issue?

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Confirm Email

Phone

Cell Phone

Date of Birth

Country of Birth

Beneficiary First Name (if applicable)

Beneficiary Middle Name

Beneficiary Last Name

Beneficiary Date of Birth

Beneficiary Country of Birth

USCIS Form

Receipt Number

Receipt Date

State Dept. Case Number and Location

I certify, under penalty of perjury, that I provided or authorized all of the information in this privacy release and any submitted documents. I reviewed and understand all of the information contained in my privacy release and any submitted documents. All of this information is complete, true, and correct. I authorize USCIS and the Department of State to release information contained in my agency records as relevant to my case, and to the extent permitted by law, to Senators Lee and his staff.

It is critical for you to provide a detailed explanation of the problem and a time line of related events. Feel free to attach a typed response or use additional paper if necessary.

Please list all forms filed with USCIS and their respective receipt numbers and receipt dates. Attach all Notices of Action for all forms filed with USCIS.

Social Security Number

Case/File Number/IRS Tax Yr:

Have you started working with another Congressional/Senate office on this issue?

If so, who are you working with?

Are you working with legal council on this issue?

If so, who are you working with?

I understand that by requesting the assistance of Senator Lee and his staff, that I am obligated to provide true and correct information regarding my situation. Failure to disclose all information or any deliberate attempt to mislead Senator Lee or his staff may result in the discontinuance of assistance.

It is critical for you to provide a detailed explanation of the problem and a time line of related events. Feel free to attach a typed response or use additional paper if necessary.

Detailed Explanation:

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