Agency Assistance Form

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Your Information

Title

Other Title

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Are You A Member of The Military or Clergy?

Military

Ecclesiastical

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Military

Military Branch*

Military Rank*

Are you Retired?

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Ecclesiastical

Ecclesiastical Title

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First Name*

Last Name*

Suffix

Pronouns

Address*

Street Address * Address Line 2 City * State * ZIP Code *

Phone Number*

Alternate Phone Number

Email*

Enter Email Confirm Email

Have you Contacted Another Congressional Office Regarding this Matter?*

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Congressional Office Contact

Whose Office Have You Contacted?

When?

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Would You Like to Designate Another Person with Whom We May Discuss the Details of Your Case?*

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Designated Person

Prefix*

First Name*

Last Name*

Suffix

Pronouns

Address*

Street Address * Address Line 2 City * State * ZIP Code *

Phone Number*

Email*

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What Can I Assist You With?

Select Agency*

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-----HOUSING

Have you Contacted a HUD-Approved Counseling Agency, Nonprofit or Other Third Party?*

Name of Agency

When Did You Contact the Agency?

Other Agency

Name of Contact at Agency

Did You Pay a Fee?

Name of Lender/Servicer

Loan Number

Are You In A Foreclosure?*

Date of Foreclosure

Are You In A Court Remediation?

Are You Seeking A Mortgage Modification?

Have You Contacted Any State Agencies?

Name Of Investor Of Loan

State Agency You Have Been Working With

Associated Account Number

All Names Associated With The Account

First Person

First Name Last Name

Last 4 of SSN

Date of Birth

Second Person

First Name Last Name

Last 4 of SSN

Date of Birth

Add more people

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All Names Associated With The Account

Third Person

First Name Last Name

Last 4 of SSN

Date of Birth

Fourth Person

First Name Last Name

Last 4 of SSN

Date of Birth

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-----U.S. Citizenship and Immigration Services

Petitioner/Applicant

Name

First Middle Last

Date of Birth

Alien number (if any)

Country of Birth

Beneficiary

Name

First Middle Last

Date of Birth

Alien number (if any)

Country of Birth

USCIS Receipt Number or Tracking Number (No Social Security Numbers)

Date of Filing

Place of Filing

Receipt Number

Section below to be completed by the person who is the subject of the records

Please complete the below section and Send to our Office

To the best of my knowledge, I certify, under penalty of 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.

I, (print your name) _____________________________________, authorize USCIS to release information contained in my USCIS records as relevant to checking my case status, and to the extent permitted by law, to Senator Alex Padilla and the Member’s staff.

Signature (sign in ink): _____________________________________ Date:

Address:

Phone: Email:

Options to send to my office:

By Mail:	By Fax:	By E-mail:
U.S. Senator Alex Padilla 600 B Street, Suite 2240 San Diego, CA 92101	(202) 228-3863	casework@padilla.senate.gov

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-----U.S. Department of State

Please Select One of the Following:

Does The Applicant Have A Petitioner?

Petitioner Info

Is the Contact Information Listed Above for the Petitioner?

Name of Petitioner

First Middle Last

Date of Birth of Petitioner

Status of Petitioner

Alien Registration Number

Please Specify

Applicant Info

Immigrant Visa Application Information

Name of Applicant

First Middle Last

Date of Birth of Applicant

Country of Origin of Applicant

Relationship to Applicant

U.S. Consulate Involved

Case Information

Receipt #

NVC Case

Name of Attorney

Phone Number of Attorney

Applicant Info

Non-Immigrant Visa Application Information

Is the Contact Info Above for the Applicant?

Name of Applicant

First Middle Last

Date of Birth of Applicant

Passport Number Of Applicant

Country of Origin of Applicant

U.S. Consulate Involved

Reason for Travel to the United States

Has Applicant Ever Applied for an Immigrant Visa, Green Card and/or Citizenship?

Date(s) of Previous Denial

Has Applicant Ever Received an Extension or Overstayed a Visa Length?

Family and Travel History

Please List Dependents Living in Home

If you need more fields than available here, add additional dependents in the description of request below.

Full Name

Relationship

Age

Full Name

Relationship

Age

Full Name

Relationship

Age

Full Name

Relationship

Age

Full Name

Relationship

Age

Number of Family Members in Home Country

Number of Years Living in Home Country

Please List any Family Members Living in The U.S.

If you need more fields than available here, add additional family members in the description of request below.

Full Name

Relationship

Age

Full Name

Relationship

Age

Full Name

Relationship

Age

Full Name

Relationship

Age

Full Name

Relationship

Age

Countries of Foreign Travel

Dates of Foreign Travel

Does Applicant Have Other Ties to Home Country Which Would Indicate Intention to Return?

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-----MILITARY

Last 4 Digits of Social Security Number*

Date of Birth*

Branch*

Rank*

Component*

Duty Station

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-----OFFICE OF PERSONNEL MANAGEMENT

Last 4 Digits of Social Security Number*

Date of Birth*

Annuitant Claim Number*

Claim Type*

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-----SMALL BUSINESS ADMINISTRATION (SBA)

Company Name*

Last 4 Digits of Social Security Number*

Date of Birth*

SBA Application Number*

Loan Number*

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-----CENTERS FOR MEDICARE & MEDICAID SVS

Please Select*

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-----MEDICARE, MEDICAID & SOCIAL SECURITY

Are You the Beneficiary?*

Beneficiary Name

Beneficiary Date of Birth*

Last 4 Digits of Your Social*

Claim Number

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-----SOCIAL SECURITY ONLY

Date Claim was Filed*

Type of Benefit*

Have You Received Determination Letter?

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-----MEDICARE ONLY

Are You A Medicare Provider?*

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-----MEDICARE & MEDICAID ONLY

Date Claim was Filed

Company Name

Address

Street Address Address Line 2 City State ZIP Code

National Provider ID Number

Name Of Attorney

Phone Of Attorney

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-----PASSPORT

Request*

Destination

Please Specify:

Departure Date*

Date of Birth*

Passport/Passport Card Locator Number

Current Processing Location

Last 4 Digits of Social Security Number*

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-----STUDENT LOAN

Date of Birth*

Type of Loan*

Please Specify

Date of Loan

Loan Servicer

Last 4 Digits of SS*

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-----VETERANS

With Which Office is Your Claim Pending?*

Are You A Veteran?*

Veteran's Name

Are You the Widow or Widower of a Combat Veteran?

Date of Birth of Veteran*

Last 4 of SSN of Veteran*

Last 4 of SSN of Beneficiary

Branch*

Rank*

Component*

Dates of Service

VA Claim Number*

Home State of Record*

Duty Station

Are You Working with a Service Rep?*

Name

Phone Number

Discharge Rating

Do You Have a Copy of Your Discharge Papers?

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-----OTHER

Name of Agency*

Reference #

Last 4 Digits of Social Security Number*

Date of Birth*

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-----FINISHING UP

Fields used at the end of multiple options

Description Of Request

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PDF Signature

Certification Under Penalty of Perjury

I, (print your name)___________________________________ , authorize USCIS to release information contained in my USCIS records as relevant to checking my case status, and to the extent permitted by law, to Senator Alex Padilla and the Member’s staff.

Signature (sign in ink):_________________________________________ Date: _______/ _______/ _______

Address:__________________________________________________________________________________

Phone:_________________________________________ Email: ___________________________

Please Sign, Date and Send to our Office

I am aware that provisions of the Privacy Act of 1974 (Public Law 93-579) may prohibit the release of information in covered agency files without my consent. I hereby give my consent for any applicable federal agency(ies) to release such information to the Office of United States Senator Alex Padilla and/or members of his staff in connection with my case or claim.

Signature: _____________________________________ Date: _______/ _______/ _______

Options to send to my office:

By Mail:	By Fax:	By E-mail:
U.S. Senator Alex Padilla 600 B Street, Suite 2240 San Diego, CA 92101	(202) 228-3863	Casework_padilla@padilla.senate.gov

Alex Padilla U.S. Senator for California

Agency Assistance Form

Your Information

Military

Ecclesiastical

Continue Form

Congressional Office Contact

Continue Form

Designated Person

Continue Form

What Can I Assist You With?

-----HOUSING

All Names Associated With The Account

All Names Associated With The Account

-----U.S. Citizenship and Immigration Services

Petitioner/Applicant

Beneficiary

USCIS Receipt Number or Tracking Number (No Social Security Numbers)

Section below to be completed by the person who is the subject of the records

Please complete the below section and Send to our Office

-----U.S. Department of State

Petitioner Info

Applicant Info

Case Information

Applicant Info

Family and Travel History

Please List Dependents Living in Home

Please List any Family Members Living in The U.S.

-----MILITARY

-----OFFICE OF PERSONNEL MANAGEMENT

-----SMALL BUSINESS ADMINISTRATION (SBA)

-----CENTERS FOR MEDICARE & MEDICAID SVS

-----MEDICARE, MEDICAID & SOCIAL SECURITY

-----SOCIAL SECURITY ONLY

-----MEDICARE ONLY

-----MEDICARE & MEDICAID ONLY

-----PASSPORT

-----STUDENT LOAN

-----VETERANS

-----OTHER

-----FINISHING UP

PDF Signature

Certification Under Penalty of Perjury

Please Sign, Date and Send to our Office

Download form to sign and caseworker will email you in 3 to 5 business days for the completed form.