Privacy Release Form
Immigration or Visa
Note: For cases where the applicant is under 16, both parents are required to be present during a minor's passport appointment. If both parents are unable to be present, please visit here to learn more about parental consent.
Please provide both parents legal names:
Note: If you have not begun the process of applying for a passport or a renewal, and your date of travel is more than 4 weeks away, please refer to travel.state.gov website on how to apply. Our office can only assist once you have applied, or if you have extremally urgent travel. Additionally, our office cannot assist with scheduling an appointment at an acceptance facility, such as a Post Office.
Note: Please attach travel itinerary in the "Attachments" section below.
Note: Please attach these files in the "Attachments" section below.
Note: Please check your refund status prior to submitting this request at www.irs.gov/refunds
US Postal Service
Location of the Post Office
Additional Information (Please enter any if the information below if it is applicable to your case)
Attach Files Here
I hereby request the assistance of the Office of United States Senator Jacky Rosen to resolve the matter described in this form. I authorize Senator Jacky Rosen and her staff to receive any information regarding this assistance. The information I have provided to the Office of United States Senator Jacky Rosen is true and accurate to the best of my knowledge and belief. The assistance I have requested from Senator Rosen's office is in no way an attempt to evade or violate any federal, state, or local law. Please Note: The Privacy Act of 1974 (5 U.S.C. § 552a) requires that Members of Congress or their staff have written authorization before they can obtain information about an individual's case. Please fill out a Privacy Release Form in order for us to process your request.
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.