Privacy Release form — U.S. Senator Tim Scott of South Carolina

The Privacy Act of 1974 (5 U.S.C. § 552a) 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 this type of request.

Step 1 of 2

Your Information

Today's Date(Required)

Prefix

First Name(Required)

Middle Name

Last Name(Required)

Date of Birth(Required)

Street Address(Required)

Street Address (2)

City(Required)

State(Required)

Zip(Required)

Email(Required)

Enter Email Confirm Email

Phone Number(Required)

Alternate Phone Number

Case Information

Which Agency Do You Need Assistance With?(Required)

Social Security Number

Tax Year

I give permission to case advocates from the IRS to contact me in regards to my case details:

Birthplace

Alien/Receipt Number

Would You Like Our Office To Share Information We Obtain On Your Behalf With Someone Else?

If yes, Please provide his/her name and contact information

Please Describe The Situation In Which You Need Assistance(Required)

Have You Contacted Another Congressional Office?(Required)

Which Congressional Office?

Hidden

PDF Signature

Certification Under Penalty of Perjury

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 Tim Scott 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 Tim Scott and/or members of his staff in connection with my case or claim.

Signature: _____________________________________ Date: _______/ _______/ _______

Print and then mail or fax your request to Senator Tim Scott at his state office closest to you:

Greenville Office:	North Charleston Office:	Columbia Office:
U.S. Senator Tim Scott 301 North Main Street Suite 1006 Greenville, SC 29601 Phone: (864) 233-5366 Fax: (855) 802-9355	U.S. Senator Tim Scott 2500 City Hall Lane 3rd Floor Suite North Charleston, SC 29406 Phone: (843) 727-4525 Fax: (855) 802-9355	U.S. Senator Tim Scott 1901 Main Street Suite 1425 Columbia, SC 29201 Phone: (803) 771-6112 Fax: (855) 802-9355