Response

Your Information

Prefix

First Name

Last Name

Suffix

Street Address

Street Address (2)

City

State

Zip

Mobile Phone

Home Phone

Confirm Email

Gender

Date of Birth

Preferred Phone Number Cell
Home

Are you a member of the military or clergy? Yes
No

How Can I Help?

FEMA Registration Number

Federal Agency Involved

Case Number

Housing Complex Name

Applicant or Petitioner? Applicant
Petitioner for a beneficiary

Applicant Information

*N/A should be used in required fields that are not applicable to your situation

Beneficiary Information

*N/A should be used in required fields that are not applicable to your situation

First Name

Last Name

Date of Birth

Gender

Address Line 1

Address Line 2

City

Phone

Beneficiary Country

Country of Birth

Beneficiary Relationship to Petitioner

Petitioner Country of Birth

Passport Number (Non-immigrant visa applicants only)

Alien Number

USCIS Receipt Number

Department of State Case Number

Type of Application Filed

IRS Case Information

Taxpayer Identification Number (SSN/EIN)

Tax Year, or Range of Years

Quarters of Tax Years

If filing jointly, please fill out the following information:

Joint Filer's Name

Joint Filer's SSN

If filing for a deceased tax filer, please fill out the following information:

Deceased's Name

Deceased's Date of Birth

Deceased's SSN

Deceased's Last Address

Medicare Number

Name used during service

Place of Birth

SSN

Veterans Affairs Claim/File Number

Component Active
Reserve
National Guard

Branch of Service

Date Entered

Date Released

Officer or Enlisted? Officer
Enlisted

Service Number

DOD ID / EDIPI #

Last Duty Station

Is this person deceased? If yes, provide a date of death.

Has this person filed a claim with the VA? If yes, pleas provide VA claim/file number.

OPM Retirement Claim Number (CSA/CSF Number)

Passport Applicant Name

Date of Birth

Date of Application

If minor, name a parent

Date/Destination of Travel

Locator/Application Number (if applicable)

Type of Service Regular
Expedited

For emergency appointment requests, you will be asked to provide evidence to show your need to travel in the next 2 weeks or 30 days if you are applying for a foreign visa. (Note: For minor children a parent's signature is required, but the full name, DOB, SSN, and date of travel are requested for each individual who needs assistance with a pending passport application or expedited passport service.)

Loan Number

Social Security field office you are working with (if known)

Student Loan/Account Number

USPS Tracking Number

Date Issue Started

US Federal Agency

Case Number (if applicable)

Authorized Point of Contact Information

First Name

Last Name

Phone

Relationship

Request Details

Are you currently working with another member of Congress? Yes
No

If yes, who?

Do you currently have a case pending before a local, state, or federal court pertaining to this matter? Yes
No

This form must be signed by the constituent seeking assistance with a U.S. federal agency.

I declare under Penalty of Perjury that the foregoing is true and correct.

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. I authorize USCIS to release information contained in my USCIS records as relevant to checking my case status, and to the extent permitted by law, to Senator Elissa Slotkin and her staff.

Constituent Name

The information I have provided to Senator Slotkin is true and accurate to the best of my knowledge and belief. The assistance I have requested from Senator Slotkin's office is in no way an attempt to evade or violate any federal, state, or local law.

Date of Signature

Note: If this is a joint return, both filers must sign in the box below.

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