Help With A Federal Agency Form

This Privacy Act generally requires your written consent before a government agency will release information to my office regarding your records. To better serve you, please complete this form, print it out, and return it with your signature to the address at the bottom of this page.

If your case involves USCIS, please click here.

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Your Information

First Name*

Middle

Last Name*

Social Security # – Required (Omit for USCIS Issues)*

Date of Birth*

Military Branch (If Applicable)

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Alternate Phone Number

Email*

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Request Details

Agency/Dept. Involved

Related Issue

Briefly explain your problem and outline the steps that have been taken by you and the agency with regard to your situation. In addition, please make your request for assistance as specific as possible. Should you require more room, feel free to attach a letter addressed directly to the Senator.

Untitled

In accordance with the provision of the Privacy Act of 1974, I authorize the Office of U.S. Senator Dan Sullivan to obtain information about me from covered agencies in connection with my case. To the best of my knowledge, the information I provided is complete, true, and correct.

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PDF Signature

PRIVACY ACT: In accordance with the provision of the Privacy Act of 1974, I authorize the Office of U.S. Senator Dan Sullivan to obtain information about me from covered agencies in connection with my case. To the best of my knowledge, the information I provided is complete, true, and correct.

Signed ____________________________________________

Date: ____ / ____ / ____

Please email, mail, or fax the signed and completed form and any attachments to:

U.S. Senator Dan Sullivan
Anchorage Field Office
510 L Street, Suite 750
Anchorage, AK 99501
Phone: 907-271-5915
Fax: 202-228-4562
Email: casework_sullivan@sullivan.senate.gov

Help With A Federal Agency Form

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