CONGRESSMAN JIM COSTA
16
th
Congressional District
PRIVACY RELEASE FORM
Name:____________________________________________________ Please circle one: Mr. Mrs. Ms. Miss
Address:_______________________________________________City:___________________Zip:_____________
Home Phone:___________________ Cell: ___________________ Email: ________________________________
Date of Birth: _______________________________ Social Security Number: __________________________
(do not fill-in if this is a USCIS case request)
Federal Agency(s) you need assistance with:__________________________________________________________
Please only fill-in the below section if it relates to your request for assistance:
USCIS: Alien Registration #:_______________________________ USCIS Case #:_________________________
USCIS Form Filed:_____________________ USCIS Office: ____________________________
Beneficiary Name on USCIS I-797 receipt form:________________________________________
Date of Birth:___________________ Country of Birth: __________________________________
US Embassy: US Embassy Contacted :_______________________ Embassy Case #______________________
Veteran: VA Case #:___________________ VA Office: ____________ Branch of Service: _____________
Years of Service: ______________________ (for veteran cases – please include copy of DD214)
Please explain the problem: __________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
In accordance with the provisions of the Privacy Act and under penalty of perjury, I certify the information in this release and inquiry
is true and accurate to the best of my knowledge and, I hereby request the assistance of Congressman Jim Costa in addressing the
matter described. I authorize Congressman Costa and his staff to receive any information from above stated federal agency(s)
which his office / staff need in order to provide this assistance.
Signature:_________________________________________________________ Date:____________________
Please return signed form along with any additional information to:
Congressman Jim Costa
Attention: Director of Constituent Services
855 M Street, Suite 940, Fresno, CA 93721
Phone (559) 495-1620 -- Fax: (559) 495-1027
CostaCasework@mail.house.gov
PR 1/2021
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