Response

Privacy Release Form

Personal Information

Prefix

First Name

Last Name

Residential Street Address Line 1

Residential Street Address Line 2

City

State

Zip

Date of Birth

Home Phone

Cell Phone

Work Phone

Country of Birth

Preferred language (if other than English)

Do you prefer a Spanish speaker contact you?
(¿Prefiere que alguien que hable español se comunique con Ud?)

Yes/Sí

I prefer to be contacted by:

Home Phone

Cell Phone

Work Phone

Case Information

Have you contacted another Nevada Congressional office or do you plan on contacting another Nevada Congressional office for assistance with this matter?

Yes

Have you contacted other office(s) (elected officials, non-profit organizations, etc.) for assistance?

Yes

If so, which ones?

If other, please explain...

I authorize Senator Rosen's office to communicate information about my case with the following family members, friends or other individuals:

Please add a brief description of the problem and your desired outcome. What steps have you taken to try to resolve the problem?

Immigration or Visa

Beneficiary First Name

Beneficiary Last Name

Beneficiary Date of Birth

Beneficiary Alien Number

Beneficiary Type of Petition

Beneficiary Interview Date

Beneficiary Country of Birth

Beneficiary Receipt Number

Beneficiary Date of Filing

Beneficiary Current Immigration Status

Embassy Involved

Passport

Which of the following are you inquiring about?

New U.S. Passport application	Renewal of U.S. Passport application
Need emergency appointment for U.S. Passport	Need assistance locating my U.S. Passport application
Need assistance locating my documents	Other

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.

If other, please explain:

Applicant First Name

Applicant Last Name

Is the applicant under the age of 16?

Yes

Please provide both parents legal names:

Parent 1

Parent 2

Applicant Date of Birth

Applicant Social Security Number

Applicant Country of Origin

Date when applicant applied for U.S. Passport

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.

Did you pay for expedited processing?

Yes

Unsure

Did you pay for 1-2 day shipping?

Yes

Unsure

Application location number

Date of Travel

Note: Please attach travel itinerary in the "Attachments" section below.

Has the applicant been issued a U.S. Passport before?

Yes

Unsure

If there is anything else you would like our office to know before we contact you, please include it here.

Social Security

If other, please specify:

Date of initial claim (mm/dd/yyyy)

Date of filing last appeal (mm/dd/yyyy)

Do you have determination forms or letters from the SSA you can provide to our office?

Yes

Note: Please attach these files in the "Attachments" section below.

Social Security Number (please re-enter here)

Please explain what assistance you are requesting from our office:

Taxes

Date of filing (mm/dd/yyyy)

Filing Method

E-filing

Paper Filing

Please specify which year

Which payment are you having an issue with?

EIP 1

EIP 2

EIP 3

If other, please specify

Were you able to access the "Refund Status" tool on www.IRS.gov?

Yes

I was not able to access this tool

I was not aware of this tool

Please enter the refund status shown on the IRS website

Note: Please check your refund status prior to submitting this request at www.irs.gov/refunds

The IRS issue is for.. (Select one)

Individual

My Business/Non-Profit

Social Security Number (please re-enter here)

Business/Non-Profit Name

Business Address Line 1

Business Address Line 2

City

State

Zip Code

Business Phone Number

Employer Identification Number (EIN)

Expected Refund Amount

US Postal Service

Tracking Confirmation Number

Where was the item mailed from?

Business

Collection Box

Other Post Office

Residence

Type of mail piece (Select one)

Envelope

Package

Do you know the contents of the mail piece?

Yes

What were the contents? (Select all that apply)

Cash/Coin	Check/Money Order	Clothing
Credit/Debit/Gift Card	Documents	Electronics
Event or Travel Tickets	Jewelry	Medications
Stamps	Other

Dollar Value of Items Mailed

Do you suspect mail theft?

Yes

Which of the following apply to your suspected mail theft? (Select all that apply)

Blue Collection Box Break-In

Break-In (i.e. Apartment Panel, Centralized Neighborhood Unit, Cluster Box, Parcel Locker)

Description of suspect or suspect vehicle

Mailed Check/Money Order was Stolen/Altered/Cashed

Photos/Videos of Theft

Witnessed Mail Theft

Have you filed a police report?

Yes

Police Report Number (if available)

Recipient's Address

Business Name

Address Line 1

Address Line 2

City

State

Zip Code

Sender's Address

Business Name

Address Line 1

Address Line 2

City

State

Zip Code

Details of the problem (Select one)

Did not submit request

Modification Request

Not working as requested

How was your change of address submitted?

Carrier

Internet

Mailed

Took to Post Office

Date you submitted your change of address (mm/dd/yyyy)

Confirmation number (if applicable)

Change of address effective date (mm/dd/yyyy)

Details of the problem

Details of problem

Hold Mail service did not cancel or end as requested	Hold Mail service did not start as requested
Issues with pick up of Held Mail	Missing Mail or Package
Some mail delivered to address during hold period	Unauthorized Hold Mail against my address

When was the request placed (mm/dd/yyyy)

Confirmation number (if applicable)

When was the hold supposed to start (mm/dd/yyyy)

When was the hold supposed to end (mm/dd/yyyy)

Details of problem

Price

Refund requested

Requested service not provided

Specify service used

Carrier pickup (free)

Pickup on demand (for a fee)

Schedule a pickup confirmation number

Details of problem

Did not submit a request

Not working as expected

Premium forwarding services submitted for

Individual

Household

Details of problem

Not received

Requested service not provided

Redelivery Confirmation Number

Date of problem (or your best guess)

What is this issue about? (Select one)

Equipment	Forms/Supplies
Incorrect Information (hours, princes, etc.)	Lobby Appearance
Other Services (Passport, PO Box, Mail Collection)	Retail Transaction

Details of Problem

Date of incident or best guess (mm/dd/yyyy)

Location of the Post Office

Address Line 1

Address Line 2

City

State

Zip Code

What is this issue about?

Bulk Mail and Business Mail Entry

Non-Profit

Date of incident or best guess (mm/dd/yyyy)

Provide CRID/MID (if applicable)

Incident location

Who is this issue about? (Select one)

1-800-ASK-USPS Agent

Letter Carrier

Post Office Clerk

Post Office Manager/Supervisor

Other USPS Employee

What is the employees name?

I have a... (Select one)

Complaint

Compliment

What is the nature of your complaint?

Never contacted customer

Poor phone courtesy

Rude/Unprofessional

What would you like to compliment USPS on?

Being Courteous

Being helpful

Being Professional

Date of incident or best guess (mm/dd/yyyy)

Incident location

Provide your username

Date of problem or best guess (mm/dd/yyyy)

If there is anything else you would like our office to know, please include it below.

Additional Information (Please enter any if the information below if it is applicable to your case)

Case Number (if applicable)

Receipt Number (if applicable)

Loan Account # (if applicable)

Claim Number (if applicable)

Passport Number (if applicable)

Housing Lender Name (if applicable)

Attached Documentation

Is additional documentation attached?

Yes

Number of Pages

Attach Files Here

Upload FileNo file chosen

Social Security Number

Signature Date

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.

Sign using your mouse or finger...

Sen. Catherine Cortez Masto	Rep. Dina Titus	Rep. Susie Lee
Rep. Mark Amodei	Rep. Steven Horsford

Dept. of Education	Dept. of Health and Human Services	Dept. of Homeland Security
Dept. of Housing & Urban Development	Dept. of State	Dept. of Transportation
Dept. of Veteran's Affairs	Internal Revenue Service	National Personnel Records Center
Office of Personnel Management	Small Business Administration	Social Security Administration
US Postal Service	Other

Friends or Family Member	Social Media	Online Search
Newsletter of office correspondence	Website	Referral form another agency
Newspaper or TV	Event	I had a prior case
Other

Active Duty Military	FEMA	Health Care
Housing and Urban Development	Immigration or Visa	Labor and Employment
Passport	Small Business	Social Security
Student Loans	Taxes	US Postal Service
Veterans Affairs	Other

I-90	I-129	I-129F	I-130	I-131	I-140
I-212	I-290B	I-485	I-526	I-539	I-590
I-600A	I-600	I-601	I-612	I-690	I-730
I-751	I-765	I-821	I-824	I-829	I-914 (Supplement A, B, or C)
I-918	I-924	I-929	N-400	N-600	N-565
Other

Retirement	Overpayment/Underpayment
Missed or Lost Monthly Benefits	Social Security Disability (SSDI)
Supplemental Security Income (SSI)	Assistance scheduling an appointment at SAA field office
Spousal or Dependent Benefits	Medicare
Social Security Card	Other

2021 Tax Return	2022 Tax Return
Child Tax Credit	Economic Impact Payment (Stimulus Check)
Other

Where is my package?	Where is my mail?
Postal Facility Issue	Business Mail Issue
Postal Service Personnel Issue	USPS.com

First-Class	Military Mail
Priority Mail	Priority Mail Express
Standard Post	Unknown

Certified Mail	Collect on Delivery
Return Receipt	Registered Mail
Signature Confirmation	Insured Mail
Other	None

Change of Address	Daily Mail Delivery
Hold Mail	Package Pickup Service
Premium Forwarding Service	Redelivery

Click-N-Ship	Informed Delivery
My Online Account	PO Box Online
The Postal Store	USPS Web Tools