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.

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?

I am aware that the Privacy Act of 1974 prohibits the release of personal information without my approval.
I, ______________, 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. 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.

Mail your document to the office closest to you or fax it to 855-802-9355.

Greenville Office:
301 North Main Street
Suite 1006
Greenville, SC 29601
Phone: (864) 233-5366
Fax: (855) 802-9355

North Charleston Office:
2500 City Hall Lane
3rd Floor Suite
North Charleston, SC 29406
Phone: (843) 727-4525
Fax: (855) 802-9355

Columbia Office:
1901 Main Street
Suite 1425
Columbia, SC 29201
Phone: (803) 771-6112
Fax: (855) 802-9355