Please print, sign and mail/fax to our office.

Name:

Date:

Agency involved: 

Numbers Identifying Case (VA claim, Alien number, tax ID, etc.): 

Branch of Service (If Applicable):

Military Rank (If Applicable):

Date of Birth:

Social Security #: 

Street Address: 
City, State, Zip Code: ,

Telephone #: 

Email Address: 

Immigration-related Information (If Applicable)

U.S. Citizenship and Immigration Services Alien #: 

U.S. Citizenship and Immigration Services Form #: 

U.S. Citizenship and Immigration Services Receipt #: 

Place of Birth: 

I, , authorize the to release personal information to Congresswoman Madeleine Dean United States Representative. I authorize Congresswoman Madeleine Dean to request and have access to all records and reports pertinent to my request for assistance in the following matter:

Nature of Problem: 

PLEASE NOTE:

The Privacy Act of 1974 requires that Members of Congress or their staff have written authorization before they can obtain information about an individual's case. We must have your signature to proceed with a casework inquiry.