Response

U.S. Senator Jeanne Shaheen
New Hampshire

2 Wall Street, Suite 220
Manchester, N.H. 03101
(603) 647-7500
Fax: (603) 647-9352

506 Hart Senate Office Building
Washington, D.C. 20510
(202) 224-2841
Fax: (202) 228-3194

COMMITTEE ASSIGNMENTS

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APPROPRIATIONS

ARMED SERVICES

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Privacy Release Form

The Privacy Act of 1974 requires written consent from the constituent before information can be obtained from a government agency's records. To better serve you, please complete this form entirely. If you are enquiring on behalf of someone else, that person must sign this form. Please be advised that all information you provide on this form will be held in the strictest confidence by my office and will not be used for any purpose other than your case.

The New Hampshire State Government website may have helpful information if you're addressing a state-level issue.

If you have questions or concerns, please feel free to contact one of my Manchester office.

How did you learn about our casework services?

Your Contact Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Home Phone

Work Phone

Cell Phone

Date of Birth

Your preferred method of contact:

Have you contacted other Congressional or Senate offices about this issue?

If yes, whom have you contacted?

Have you or your family ever served in the military?

Would you like to authorize Senator Shaheen's office to communicate information about your case with someone else?

Designee's Name/Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Your designee's relationship to you:

If other, please specify.

Federal Agencies Involved:

If you are experiencing any of the hardships indicated below as a result of your issue, please inform us by checking all that apply: Notice of Eviction
Notice of Foreclosure
Notice of Levy
Notice of Lien
Notice of Utility Shutoff
Homelessness
Unemployment

Please provide any copies of these notices to our office so we may inform the agency of the urgency, in the attachment section located on the bottom of this form.

Social Security Number

Education Issue Type (Choose one)

If other, please specify.

Type of Student Loan

Student Loan Servicer (If private)

Housing Issue Type (Choose one)

What is the name of your mortgage servicer?

Has your servicer initiated the foreclosure process?

If so, when is your sale date?

Have you already contacted your servicer about loss mitigation options?

If so, when?

Have you already filed a complaint with the Consumer Financial Protection Bureau?

If so, what is your complaint number?

If you are not the applicant, please have this form completed and signed by the applicant only.

For deportation issues, please download fill out ICE's privacy release form, then come back to this page and upload it in the attachment section below.

Visit https://www.ice.gov/node/60831.

Who are you (the petitioner) filing for?

Immigration Issue Type (Choose One)

Your A #:

Your Place of Birth

Your Current Immigration Status

Immigration Issue Type (Choose One)

Full Name of Beneficiary

Beneficiary's Current Immigration Status

Beneficiary's A #:

Beneficiary's Date of Birth

Beneficiary's Place of Birth

Case Number

If other, please specify:

Are there any derivatives on your case?

Priority Date(s):

Consulate(s) or Service Center(s) Involved:

Social Security Number or Business EIN:

Type of Tax Issue

Tax Year(s) Involved:

Type of Return(s)

Were any of these tax returns filed jointly?

If you need assistance with a joint return, please visit our website here to download a privacy release form and obtain directions on how to send it in as we will need both your and your spouse's signature.

Do any of these returns involve a decedent?

What are you having problems with?

Medicare Number

Rank

Unit

Duty Station

Veteran's Case Number (If applicable)

Do you need assistance with military medals or records?

Have you already submitted a request for medals or records?

If yes, please provide the case number:

For all requests, please attach a copy of the SF180--Request Pertaining to Military Records.

Have you already submitted a claim?

If yes, what type?

Have you worked with a Veteran Service Officer (VSO) to prepare any claims?

Do you also need assistance with Social Security Disability?

Applicant Name (As it would appear on passport)

Are you submitting this request on your or someone else's behalf?

Applicant's Date of Birth

Applicant's Social Security Number

Date of Application

Date of Travel

Location or Post Office

Did you choose standard processing or pay the expedited processing fee?

Did you choose standard return shipping, or was overnight shipping elected?

Address where passport would be delivered:

Passport Application Locator Number

Attention! You must provide a copy of your travel itinerary that includes your name, date of travel, and flight number.

Please confirm you have uploaded a copy (.jpg or .png screenshot or .pdf) of your itinerary in the attachment section provided at the bottom of this form.

Type of Claim Filed

Has the claim been denied?

Office you are dealing with:

Please state the nature of your request, problem, or complaint and how you would like the Senator to assist you. Please be specific and, if necessary, attach a short letter and/or copies of any relevant documents or notices.

Please state how you would like Senator Shaheen to help you.

Attach any short letters and/or copies of any relevant documents or notices here. Allowed file types include .doc, .docx, .jpg, .pdf, .png, or .txt. Total file size limit is 15MB.

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*If the applicant is a minor (under 18 years old), a parent or legal guardian must sign this privacy release for them.

I freely and willingly authorize Senator Shaheen and her staff to make inquiries into my personal records, and/or files to obtain information about me pertaining to my request for assistance. I understand that I may revoke this authorization at any time.

I certify, under penalty of perjury, that I provided or authorized all of the information in the privacy release and any document submitted with it; I reviewed and understand all of the information contained in my privacy release and submitted with it; and all of this information is complete, true and correct.

If your request for casework assistance is time-sensitive, please follow up with a phone call to Senator Shaheen's Manchester office at 603-647-7500.

Today's Date

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