Response

PRIVACY RELEASE and CONSTITUENT INFORMATION FORM

My office is happy to help in your interactions with agencies and offices of the federal government. Casework is available to all Oregonians and covers a variety of issues. My office inquires about pending cases from passport applications to social security and veterans’ benefits. While my office cannot file, adjudicate, or appeal your case, we will work to ensure the federal government is responsive to your concerns.

Due to the Constitution's separation of powers, and Senate ethics rules, I am not permitted to assist in judicial or court matters, including child custody/support, divorce, criminal trials, lawsuits or imprisonment.

***

The Privacy Act of 1974, Title 5, U.S. Code Section 552a, provides that as of September 27, 1975, disclosure of information of a personal or confidential nature of an individual will no longer be released to third parties without written consent of the individual concerned. Therefore, I hereby grant Senator Jeff Merkley and his staff my written permission to intercede on my behalf. I also duly authorize that any information that is contained in my records and necessary to provide a substantive response may be disclosed to the Office of Senator Merkley.

Your Contact Information

Prefix

First Name

Middle Name

Last Name

Preferred Phone Number

Secondary Phone Number

Address Line 1

Address Line 2

City

State

Zip

Email Address

Date of Birth

Would you like to designate someone with whom we may discuss the details of your case?

Yes

Their relationship with/to you:

Designee's Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Would you like to designate a second person with whom we may discuss the details of your case?

Yes

Their relationship with/to you:

Designee's Information (#2)

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Case Details

What is the general nature of your request?

Citizenship & Immigration	Health Care and Health Insurance	Housing and Home Ownership
Military and Veterans	Passports and Foreign Travel	Social Security and Retirement
Education & Student Loans	Taxes and the IRS	All Other Requests for Help

Which government agency (or agencies) have you been working with?

Have you contacted another Congressional office?

Which office?

When?

The type of help you are seeking:

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 at the bottom of this form.

Visit https://www.merkley.senate.gov/wp-content/uploads/2023/07/ICE-Privacy-Waiver.pdf.

I am filing for...

If other, please specify

Your Alien Registration Number

Your USCIS Receipt Number

Your Place of Birth

Application or Petition Type

Interview Date (if any)

Your Current Immigration Status

Beneficiary Full Name

Beneficiary Date of Birth

Beneficiary Place of Birth

Application Type

Beneficiary's USCIS Receipt Number

Beneficiary's Alien Number

Beneficiary's Interview Date (if any)

USCIS Receipt Number

Consular Case Number

Visa or Petition Type

If other, please specify.

Name of the Person Seeking Visa

Gender for Person Seeking Visa

Birthdate for Person Seeking Visa

Alien Registration Number of Person Seeking Visa

Place of Birth of Person Seeking Visa

Current Country of Residence of Person Seeking Visa

Passport Number of Person Seeking Visa

Your Relationship to Person Seeking Visa

Interview date (if any):

Are there other people included with this application?

Please specify the following information for each additional person:

Name

Birthdate

Alien Registration Number

Country of Birth

Country of Residence

Passport Number

Relationship to Person

The type of help you are seeking:

What type of health coverage do you need help with?

Medicare ID Number

If you already attempted to obtain health care or health insurance unsuccessfully, please describe the efforts you've already undertaken.

Company providing health insurance:

Insurance Identification Number

Have you already contacted the insurance company?

Insurance Contact Name

Insurance Contact Information

Do you need help with the VA medical system, Tricare, or other?

Tricare Identification Number

The type of help you are seeking:

Have you contacted a HUD-approved housing counselor?

Which agency, nonprofit, or third party?

When?

Contact at agency:

Name of Lender/Servicer

Loan Number

Is there a foreclosure sale or court date scheduled?

Date of Foreclosure Sale/Court Date

Name of Investor of Loan

The type of help you are seeking:

Branch of Service

Unit Information

Claimant's Date of Birth

Current Duty Station

Base

Current Address Line 1 (if different than stated above)

Current Address Line 2

Current City

Current State

Current Zip Code

Home of Record

Home of Record Address Line 1

Home of Record Address Line 2

Home of Record City

Home of Record State

Home of Record Zip Code

Are you currently working with a Veterans Service Officer?

VSO Name

VSO Contact Information

Type of Veterans Benefits Sought

Case Number, Registration Number, or Other Identifying Information

Claimant's Date of Birth

For assistance with Tricare, please download fill out the DD form 2870, then come back to this page and upload it in the attachment section at the bottom of this form.

Visit https://www.merkley.senate.gov/wp-content/uploads/2023/07/Tricare-Disclosure-of-Medical-or-Dental-Info.pdf.

The type of help you are seeking:

Your Relationship to Applicant

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

Full Name of Applicant

SSN of Applicant

Date of Birth of Applicant

Passport Application Locator Number (if known)

Date of Travel (if Known)

Passport Number

Contact Information While Traveling Abroad (if different than above)

Phone Number

Secondary Phone Number

Street Address

Street Address (2)

City

Province/Region

Country

What is the best way for us to reach you while you are traveling abroad?

The Department of State also requires proof of travel to expedite an application based on an urgent upcoming trip. Please confirm that you have enclosed/attached proof of travel (e.g., official flight itinerary) in the attachment section below.

Yes

The type of help you are seeking:

Claimant's Social Security No.

Claimant's Date of Birth

OPM Retirement Claim No.

Current or last federal agency that employed you:

What type of retirement plan do you need help with?

Were these benefits provided by an employer?

Name and Address of Employer

Name of Employer

Street Address

Street Address (2)

City

State

Postal Code

What type of student loan do you need help with?

Name of Loan Guarantor

Loan Identification Number

The type of help you are seeking:

Type of Return

Decedent

Individual

Joint

Trust

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.

Tax Year(s)

Social Security No.

IRS Form Filed

Business Owner/Principal Officer Contact Info

Title

First Name

Last Name

Suffix

Business/Organization Name

Address Line 1

Address Line 2

City

State

Zip

Verify Email

Preferred Phone Number

Secondary Phone Number

Additional Information

Date of Birth

Employer ID Number

Type of Tax Return or Form Filed

Taxable Period

Decedent's Name

Federal Tax ID/or SSN

Your Relationship to the Deceased's Estate/Trust

Type of Tax

Tax Form Number(s)

Tax Years

Date of Birth

Latest Address

Social Security Number

What do you need help with? *(please describe the problem in as much detail as necessary)

**Please note that there is a limit of 650 characters and longer explanations can be attached below.**

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

Upload FileNo file chosen

Today's Date

Sign using your mouse or finger...