Response

Privacy Act Release Form — U.S. Department of State (Passports)

Senator Warner’s office stands ready help you work through a problem you may have with a federal agency. Acting as a liaison between you and the federal government, office staff can often help you answer questions, find resources or resolve problems. The office cannot promise you a specific outcome from an agency or referral. Staff will do their best to help you receive a full and fair response.

In accordance with the provisions of The Privacy Act of 1974 (5 U.S.C. § 552a ), your written consent is required so that we may contact a federal agency on your behalf. Since e-mails do not contain a valid signature, they do not fulfill the requirements of the law.

-In order for my office to assist, I must have a completed Privacy Act Release form for each individual in need of a U.S. Passport, including one for each minor child.

PRIMARY APPLICANT (IF 18 OR OLDER) OR PARENT/GUARDIAN (IF APPLICANT IS A MINOR).

Prefix

First Name

Middle Name

Last Name

Suffix

Address

City

State

Zip

Primary Phone Number

Secondary Phone Phone

Date of Birth (Please enter MM/DD/YYYY)

Social Security Number

MINOR APPLICANT (REQUIRED IF THE PASSPORT APPLICATION IS FOR A MINOR)

Minor's Name: (Please include the Minor's Full Name: First, Middle, Last and Suffix)

Minor's Date of Birth:

Minor's Place of Birth:

Minor's Social Security Number:

THIRD PARTY AUTHORIZATION (OPTIONAL)

If you want information regarding your case released to a third party (spouse, family, attorney, etc.) please provide the following information:

Name(s) and relationship:

E-mail:

Third Party Contact Information

Prefix

First Name

Middle Name

Last Name

Suffix

Address Line 1

City

State

Zip

Primary Phone Number

Secondary Phone Number

ADDITIONAL INFORMATION

If you have confirmed travel plans, please be prepared to provide evidence of your international travel before you submit your form.

Travel Date:

Have you filed your passport application with the Department of State?

If yes, please answer the following:

Date of submission:

Passport Locator Number:

How was your application submitted?

When you applied, did you select Expedited or Routine Processing?

When you applied, did you select Standard or Express Shipping?

If Routine, please know Routine Processing can take as long as 8 weeks. To expedite your application, you will need to upgrade each individual application to expedited service and pay the $60 fee per application. You can also upgrade your return delivery to express delivery for a $21.36 charge per application. If you applied via routine service and need to upgrade your application to expedited service, please provide credit card information with this form or call our Roanoke office for assistance.

If you have contacted another congressional office to assist you, please list the office:

Briefly state your problem and the outcome you are seeking below. (Space is limited to 1,500 characters)

Please attached the supporting documents, up to three files and no larger than 15MB a piece.

Please upload proof of upcoming international travel. This information is requested by the State Department in order to appropriately prioritize your case.

This evidence can be a flight itinerary from the airline, hotel reservation, cruise tickets, international car insurance, etc. Please make sure that this evidence does display the applicant's name and an international destination.

If you are traveling under life or death circumstances, please note that the State Department requires medical documentation in English or a verified English translation explaining the circumstances.

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2nd Attachment

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3rd Attachment

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If you have questions about completing this form, please contact the Roanoke office at 540-857-2676.

DATE AND SIGNATURE

I hereby authorize the U.S. Consular Office of the United States of America and the U.S. Department of State to release information regarding myself or the identified minor child to the Office of U.S. Senator Mark Warner. Further, I authorize the Office of Senator Mark Warner to make appropriate inquiries on my behalf pertaining to my request for assistance, including any relevant information associated with my request.

Today's Date:

This signature must be from an individual who is 18 years of age or older. Third party signatures, including those of immediate family members, are not acceptable.

Signature must be in your handwriting.

Sign using your mouse or finger...