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2
Brief description of the issue (if you need more space, attach a separate sheet):
Staff Member (print): _________________________________ Phone: _________________________
Email: _____________________________________________
Section below to be completed by the person who is the subject of the records:
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/Representative ___________________________ and the Member’s staff.
Signature (sign in ink): ____________________________________________ Date: ________________
Address: _____________________________________________________________________________
Phone: ____________________ _____ Email: _____________________________________________