Response

Privacy Act Authorization Form

In accordance with the requirements of the Privacy Act of 1974, which protects my confidential records from unauthorized release, I am taking this opportunity to give Senator Susan Collins and her staff permission to receive information in my records relative to her inquiry on my behalf.

If this is an emergency or you have additional questions, please feel free to contact one of my state offices here.

Petitioner/Applicant Information

County of Residence

ATTENTION!! In order to reactivate the submit button on the bottom of this form, your county choices MUST match. Please correct your choices before proceeding. Thank you!

Please note this form should be filled out by the person needing assistance. If you have any issues completing this form online, please contact the Senator's Augusta Office at (207) 622-8414.

Please note this form should be filled out by the person needing assistance. If you have any issues completing this form online, please contact the Senator's Bangor Office at (207) 945-0417.

Please note this form should be filled out by the person needing assistance. If you have any issues completing this form online, please contact the Senator's Caribou Office at (207) 493-7873.

Please note this form should be filled out by the person needing assistance. If you have any issues completing this form online, please contact the Senator's Lewiston Office at (207) 784-6969.

Please note this form should be filled out by the person needing assistance. If you have any issues completing this form online, please contact the Senator's Portland Office at (207) 618-5560.

Please note this form should be filled out by the person needing assistance. If you have any issues completing this form online, please contact the Senator's York Office at (207) 283-1101.

Prefix

First Name

Last Name

Suffix

Address Line 1

Address Line 2

City

State

Zip

Phone

Date of Birth

RequiredHow are they related?

Designee's Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Social Security Number

Last Four Digits of SSN

Case Information

Loan Number

Name of Loan Provider

For assistance with the Department of Health and Human Services, please download and fill out the Authorization to Release Information, then come back to this page and upload it in the attachment section provided below.

Petitioner Alien Number

Petitioner Country/Place of Birth

Agency Case Number

If other, please specify

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

Type of assistance needed:

RequiredReturn Type

Individual
Individual (Estate/Trust)

EIN (Employer Identification Number)

Name of Business (As it appears on return)

RequiredPosition Title

RequiredAre you authorized to consent on behalf of of this organization/business?

Yes
No

RequiredName of Deceased

RequiredFederal Tax ID/SSN of Deceased

RequiredYour relationship to the deceased/estate/trust

RequiredTax Type

Tax Year(s)

IF APPLICABLE TO YOUR CASE, please upload a copy of your insurance card in the attachment section provided on this form below.

What type of assistance are you seeking?

For assistance with MaineCare, please download and fill out the Authorization to Release Information, then come back to this page and upload it in the attachment section provided below.

Date(s) of Travel (Please include if available)

Did you expedite your passport application?

Passport Number

Passport Locator Number

For assistance with passports, please ensure you have uploaded copies of your travel/flight itinerary, wedding invite, or funeral notice etc., in the attachment section provided below.

*Failure to provide all requested information and documents will result in significant delays in processing.

On what date did your issue occur?

Did your issue occur with delivery, online, or at a post office?

Location of Post Office

Relevant Tracking Numbers

If applicable to your case, please upload and attach a copy of your DD Form 214 (Certificate of Release or Discharge from Active Duty) in the attachment section provided below.

Entered Military Date

Separated from Military Date

Branch of Military

Brief Description of Issue

RequiredIs another congressional office currently assisting you with this issue?

Attach copies of any relevant documentation here.

You may upload multiple attachments, however there is a cumulative maximum file size limit = 15MB. You may send additional documentation directly to the staff member assigned to your case after they have made contact with you.

***Allowed file types: .doc, .docx, .jpg, .pdf, or .png***

(Maximum File(s) Size = 15000000 bytes / 15MB)

Upload FileNo file chosen

Today's Date

The signature must be from an individual who is 18 years of age or older and is requesting assistance or has a pending case with a federal agency. If the individual is unable to sign, a legally authorized representative - such as someone holding power of attorney or a legal guardian - may sign on their behalf. Proper documentation confirming the representative's legal authority must be provided. Third-party signatures, including those of immediate family members without legal authority, are not acceptable. Federal agencies will not release information without the signed consent of the appropriate individual or their authorized representative.

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