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

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:
Name _____________________________________________________________________

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

Address____________________________________________________________________

City__________________________________ZIP__________________________________

Home Phone_____________________Work Phone_________________________________

Email Address:______________________________________________________________

Social Security #________________ Alien number: A ______________________________

Date Of Birth:_______________________________________________________________

Place Of Birth_______________________________________________________________

Form That Was Filed With The USCIS:___________________________________________

Date Filed With The USCIS:____________________________________________________

USCIS Receipt Number: ______________________________________________________

USCIS Office Where Form Was Filed:¬____________________________________________

Signature___________________________________________________________________

Information about the Petitioner (if applicable):
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):

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?