Response

JD VANCE

UNITED STATES SENATOR FOR OHIO

37 West Broad Street, Room 300 • Columbus, OH, 43215 • Phone: (614) 369-4925

PRIVACY RELEASE and CONSTITUENT INFORMATION FORM

The office of U.S. Senator JD Vance is happy to help in your interactions with agencies and offices of the federal government. Assistance is available to all Ohioans and covers a variety of issues. Among other topics, the Senator's office routinely receives inquiries about pending cases from passport applications to Social Security and veterans’ benefits. While our office cannot file, adjudicate, or appeal your case, we will work to ensure the federal government is responsive to your concerns. Additionally, the work our office provides on a constituent’s behalf does not create an attorney-client relationship and is not a substitute for legal representation.

Due to the Constitution’s separation of powers, Senator Vance cannot assist in judicial or court matters, including child custody/support, divorce, criminal trials, lawsuits or imprisonment. Additionally as a United States Senator, he has no jurisdiction over state issues such as:

County social services
Medicaid
State taxes
State unemployment
State workers' compensation
Domestic disagreements/disputes
Criminal justice/court decisions

Pursuant to Public Law 93-579, the Privacy Act, I (i.e., the constituent) hereby authorize Senator JD Vance and/or his staff to request and receive information from the appropriate federal agency or department in reference to my inquiry. This authorization includes written correspondence, telephonic, or any other means of communication. The federal agency or department is authorized to furnish copies of any documents, correspondence, or information relative to my inquiry until the matter is resolved.

Your Information

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Home Phone Number

Mobile Phone Number

Work Phone Number

Date of Birth (mm/dd/yyyy)

Has another Congressional or Senate office been contacted to assist you regarding this issue?

Yes

If yes, please list the office:

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

Yes

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

Designee's Information (#2)

Prefix

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

If "Other", please specify

Social Security Number

Due to the Constitution's separation of powers, Senator Vance cannot assist in judicial or court matters.

Agency Name:

ATF (please contact the office for an additional required form)

Federal Bureau of Prisons

Other

If "Other", please specify

While Medicaid is federally funded, Ohio state officials are in charge of the administration of this program. Please contact the Ohio Department of Medicaid at 800-324-8680, and/or your local state representative or state senator for assistance."

Healthcare Issue Type (Choose one)

Medicare Beneficiary Number (MBI)

Applicant's Name

Type of Application or Form Filed

Alien Registration Number

Receipt Number

Applicant's Date of Birth

Applicant's Place of Birth

Petitioner's Place of Birth

Is this a personal or business related tax issue?

Business

Personal

Taxpayer Identifying Number

Spouse's Name

Spouse's Taxpayer Identifying Number

Date Return Filed

Signed Copy of Return Attached (use the attachment section below)

Tax Form Number

Tax Year(s)

Please describe the tax issue you are experiencing and any difficulties it may be creating.

Please describe the relief/assistance you are requesting

Under the Authority of the IRC § 6103(c), I, the undersigned, authorize the above named individual or his/her staff to investigate and receive information pertaining to the matter described above.

Taxpayer Name

Name of Business

Employer Identification Number

Name of Business Owner

Street Address of Business

City

State

ZIP Code

Date Return Filed

Tax Form Number

Tax Period(s)

Signed Copy of Return Attached?

Please describe the tax issue you are experiencing and any difficulties it may be creating.

Please describe the relief/assistance you are requesting.

Representative Title

If your issue involves an unemployment claim or workers' compensation issue with an employer other than the federal government, your claim would fall under the purview of the state of Ohio. Please contact the necessary state agency or your local state representative or state senator.

Labor and Unemployment Issue Type

Which Government agency have you been working with?

Department of Labor

Equal Employment Opportunity Commission

Federal Office of Workers' Compensation

National Labor Relations Board

Other

If other, please specify.

Federal Employing Agency

Claim Number

Date of Injury

Name of Treating Physician(s)

Military Case Type

Reference #

CSA or CSF Number of Annuitant

SSN of Annuitant

Date of Retirement

Employing Agency

Expedite fee paid?

Locator #

Application Date

Travel Date

Destination

Small Business Issue Type

Application or Loan Number

Date of Application

Name of Lender

Date of Application for Forgiveness

Applicant or Number Holder Information

Type of Claim Filed

Current Level of Claim

Date Filed

Claim Status

First Name

Middle Name

Last Name

Date of Birth

Veteran Case Type

Are you a veteran?

Veteran's Name

Are you the widow or widower of a combat veteran?

Veteran's Date of Birth

Dates of Service

VA Claim #

Duty Station

Working with a Veterans Service Organization (VSO)?

Do you have a copy of your discharge papers?

VA Case/C-File #

Branch of Service

Rank/Grade/Unit

Are you working with a patient advocate/service officer? If so, who?

Briefly explain your problem and/or request for assistance (Include additional pages if needed or copies of any documentation that may help expedite your inquiry, in the attachment section below.):

Attach copies of any relevant documentation. ***NOTE: ALL ATTACHMENTS MUST BE .doc, .docx, .pdf, or .txt (i.e., NO PHOTOGRAPHS).*** Maximum file size = 15MB. You may send additional documentation directly to your caseworker after they have made contact with you.

Upload FileNo file chosen

I am aware that provisions of the Privacy Act of 1974 (Public Law 93-579) prohibit the release of information in my file without my approval. I hereby authorize the above-mentioned agency (agencies) to provide information regarding my case or claim to the Office of United States Senator JD Vance. I certify, under penalty or 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 to be fully compliant with 6CR 5.21(d).

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