Help with a Federal Agency - Print
Congressman Brad Schneider
Please print, sign and mail/fax to our office.
Street Address: [required-address]
City, State, Zip Code: [required-city], [required-state] [required-zip]
Email Address: [required-valid-email]
Telephone #: [required-phone]
Date of Birth: [required-birth]
Social Security #: [required-ssnum]
Federal Agency Involved: [required-agency]
Number identifying case (VA claim, IRS tax year) – if applicable: [case-number]
For IMMIGRATION Help Only:
Name of Applicant: [applicant-name]
Name of Beneficiary: [beneficiary-name]
Country of Birth: [birth-country]
Alien Registration Number (A-Number): [alien-number]
USCIS Receipt Number – if applicable: [uscis]
Type of application (N-400, I-765, etc): [application-type]
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.
SIGNATURE FOR RELEASE
I, (print your name) _____________________________________, certify, under penalty of perjury, that I provided or authorized all of the information provided in this privacy release and any documents submitted with it, and attest that the information is complete, true, and correct. I authorize USCIS/Department of State to release information contained in my USCIS/DOS records as relevant to checking my case status, and to Representative Brad Schneider and his staff, which under the Privacy Act of 1974, cannot be released without my written consent. I am therefore consenting to the release of information protected by statute.
Signature (sign in ink): ___________________________________ Date: _________________
Print, and then mail or fax your request to Congressman Brad Schneider at the following address.
Applicants can also return the form and attachments to our District Office:
Office of Congressman Brad Schneider
11 Barclay Blvd., Suite 200
Lincolnshire, IL 60069
via fax at 847-793-0677
via email at Karyn.firstname.lastname@example.org