WRITTEN AUTHORIZATION UNDER THE PROVISIONS OF THE PRIVACY ACT OF 1974
For Immigration/Naturalization Casework

Click here to fill out the PDF or fill out the web form below.

Date:__________________________

Dear Congressman Holt,

I would like to request assistance with the following problem I am having with the U.S. Citizenship and Immigration Services (formerly the INS). In keeping with the restrictions of the Privacy Act of 1974, I am authorizing you and/or your staff to request information about me, which would be required in your investigation of the matter, outlined below.

Please Print or Type:

Mr. or Ms. (Circle One) Name: ___________________________________________

Other Names Used (Maiden, aliases, etc.): ________________________________

Address: ___________________________________________________________

City: __________________________________ ZIP: _______________________

Home Phone: _____________________ Work/Cell Phone: __________________

Email Address: _____________________________________________________

Social Security: ________________ Alien number: A______________________

Date of Birth: ______________________________________________________

Place of Birth: ______________________________________________________

Form That Was Filed With USCIS: _____________________________________

Date Filed With USCIS: ______________________________________________

USCIS Receipt Number: ______________________________________________

USCIS Office Where Form Was Filed: ___________________________________

Signature __________________________________________________________

Who paid for the petition/application? (Circle One)

I paid     Someone else paid     It was free

Information about the Petitioner (if applicable):

Mr. or Ms. (Circle One) Name: ___________________________________________

Date of Birth: _______________________ Place of Birth: ___________________

Alien Registration Number: A___________________________

Check one: [ ] U.S. Citizen [ ] U.S. Lawful Permanent Resident (“Green Card” holder) [ ] Permanent resident of another country (Which country? ___________)

Information about the Beneficiary (if applicable): (for more than one beneficiary, please complete attached page 3)

Name: _____________________________________________________________

Date of Birth: _______________________ Place of Birth: ___________________

Alien Registration Number: A___________________________

Check one: [ ] U.S. Citizen [ ] U.S. Lawful Permanent Resident (“Green Card” holder) [ ] Permanent resident of another country (Which country? ___________)

Briefly explain the nature of your complaint or concern and attach copies of any relevant receipt notices or documents you may have:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

What steps have you taken so far, and what have been the results? Please include the names of agencies and persons you have contacted?

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

What would you consider a fair outcome?

Thank you.

Please return this form to:
Rep. Rush Holt
50 Washington Road
West Windsor, New Jersey 08550

Fax: (609) 750-0618

www.holt.house.gov