WRITTEN AUTHORIZATION UNDER THE PROVISIONS OF THE PRIVACY ACT OF 1974
For Non-Immigrant Visitor Visa

Date:__________________________

Dear Congressman Holt,

I would like to request assistance with the following problem I am having with the U.S. Embassy/Consulate listed below. In keeping with the restrictions of the Privacy Act of 1974, I am authorizing you and/or your staff to request information on me, which would be required in your investigation of the matter, outlined below.

Please Print or Type:
Name________________________________________________________

Address_______________________________________________________

City__________________________________ZIP_____________________

Home Phone_____________________Work Phone____________________

Email Address:_________________________________________________

Social Security#________________________________________________

Signature______________________________________________________

Name of Visa Applicant___________________________________________

Applicant’s Date of Birth__________________________________________

Applicant’s Current Address________________________________________

Embassy or Consulate being used____________________________________

Has an appointment for an interview been set?__________________________

What is the date and time of the interview?_____________________________

Has an application already been denied?_______________________________

Briefly explain your relationship to the visa applicant and his/her reason for wanting to come to the United States

At what point in the visa application process is the applicant? (e.g. Has an application been submitted? Has an appointment for an interview been set? Has an application already been denied?)

What ties to the home country can the applicant demonstrate? (e.g. Is he/she married? Does he/she own a home or have a good job? Do his/her parents and/or siblings still live there?) Please answer with as much detail as the Department of State seeks compelling evidence that each visitor is not an intending immigrant.