Office of Personnel Management

"*" indicates required fields

Your Information

Title*

First Name*

Last Name*

Date of Birth*

Email*

Phone*

Phone Type*

Alternate Phone

Phone Type

Address*

Street Address * Address Line 2 City * State * ZIP Code *

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Have you Contacted

Have you Contacted Sen. Markey or your House Representative Regarding this Matter?*

Whose Office Have You Contacted?

When?

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would you like

Would You Like to Designate Another Person with Whom We May Discuss the Details of Your Case?*

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Would you like hidden fields

Title*

First Name*

Last Name*

Address*

Street Address * Address Line 2 City * State * ZIP Code *

Email*

Phone*

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Do you currently

Do you currently have a case pending before a local, state, or federal court regarding this matter?*

How can I Help?

Select Agency*

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-----IRS

SSN*

EIN (if applicable)

TIN (if applicable)

Date of Birth

Case Number (if applicable)

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-----Immigration, Citizenship, and Visas

I am the...*

Petitioner

Beneficiary

Petitioner Information

First Name*

Last Name*

Date of Birth*

Country of Birth*

Alien number (if applicable)

Do you have a beneficiary?*

I have a beneficiary

I do not have a beneficiary

Beneficiary Information

First Name

Last Name

Date of Birth

Country of Birth

Alien number (if applicable)

Additional Information

Petition Form Types

Receipt Number*

Interview Date

Priority Date

USCIS Service Center (if applicable)

U.S. Embassy (if applicable)

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-----MEDICARE & MEDICAID

Please Select*

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-----MEDICARE

Type of Medicare*

Provider*

Are You the Beneficiary?*

Beneficiary Name

Beneficiary Date of Birth*

Social Security Number*

Claim Number

Are you a healthcare provider?*

Company Name

National Provider ID Number

Address

Street Address Address Line 2 City State ZIP Code

Date Claim Was Filed

Name of Attorney

Phone of Attorney

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-----MEDICAID

Are You the Beneficiary?*

Beneficiary Name

Beneficiary Date of Birth*

Social Security Number*

Claim Number

Date Claim Was Filed

Name of Attorney

Phone of Attorney

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-----STUDENT LOAN

Social Security Number*

Student Loan Number*

Date of Birth*

Please Select*

Department of Education

MOHELA/Other Loan Servicer

Distributor*

Type of Loan*

Date of Loan

Loan Servicer

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-----VETERANS

With Which Office is Your Claim Pending?*

Are You A Veteran?*

Veteran's First Name

Veteran's Last Name

Are You the Widow or Widower of a Combat Veteran?

Date of Birth of Veteran*

Social Security Number of Veteran*

Service Number

Social Security Number of Beneficiary*

Branch*

Rank*

Component*

Date of Service

VA Claim Number

Home State of Record*

Duty Station

Are You Working with a Veterans Service Officer (VSO)?*

First Name

Last Name

Phone Number

Character of Discharge

Do You Have a Copy of Your Discharge Papers?*

Unit Information

Please attach dd214 or dd214-1 form, discharge papers, Statement of Service or Retirement notice attachments, VA benefits determination letters attachments, and/or previous VA correspondence when submitting your casework request.

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------Military

Social Security Number*

Date of Birth*

Date of Service From:*

Date of Service To:*

Branch*

Rank*

Component*

Duty Station

Service Number

Unit Information

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------Office of Personnel Management

Last 4 Digits of Social Security Number*

Date of Birth*

Annuitant Claim Number

Claim Type*

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------Passports

Request*

Destination

Please Specify

Do you have upcoming travel in the next 14 days?

Date of Travel*

Date of Birth*

Date Applied*

Passport/Passport Card Locator Number

Current Processing Location

Social Security Number*

If you have already applied+paid for expedited processing please send us proof of your imminent travel along with your casework submission.

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-------Social Security

Are You the Beneficiary?*

Beneficiary First Name

Beneficiary Last Name

Beneficiary Date of Birth*

Social Security Number*

Claim Number

Date Claim Was Filed

Type of Benefit*

Have you received a determination letter?*

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-------General

Name of Federal Agency*

Social Security Number*

Reference #

Service Request Number (if applicable)

Date of Birth*

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-----FINISHING UP

Fields used at the end of multiple options

Please provide a brief explanation of your reason for requesting assistance from Senator Elizabeth Warren’s office in the space provided below:*

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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 Elizabeth Warren and the Member’s staff.

Signature (sign in ink):_________________________________________ Date: _______/ _______/ _______

Address:__________________________________________________________________________________

Phone:_________________________________________ Email: ___________________________

Please Sign, Date and Send to our Office

U.S. Senator Elizabeth Warren and members of her staff have my permission to make inquiries on my behalf, including access to my personal records and/or files as necessary to assist me in the matter that I have presented to her office.

Signature: _____________________________________ Date: _______/ _______/ _______

Options to send to my office:

By Mail:	By Email:	By Fax:
U.S. Senator Elizabeth Warren 2400 JFK Federal Building 15 New Sudbury Street Boston MA 02203	casework@warren.senate.gov	202-228-4850

Please download, sign, date, and send this form to our office.

REVIEW & DOWNLOAD

Download PDF

The Federal Privacy Act of 1974 (Public Law 93-579) requires us to have your written permission before we contact government agencies on your behalf or discuss your case in detail. After completing the form above, please click "Submit and Generate PDF" below for a printable PDF copy of the Privacy Act Waiver form with your information.

Or you can download a Privacy Act Waiver form and fill it out yourself:

Privacy Act Waiver for non-immigration cases (English)
Spanish, Arabic, Chinese, Haitian Creole, Cape Verdean Creole, Khmer, Portuguese, Vietnamese

Once your form is filled out and signed with your original signature, please return it to my Boston office by doing one of the following:

Email: casework@warren.senate.gov

Fax: 202-228-4850

Mail:
Senator Elizabeth Warren
2400 JFK Federal Building
15 New Sudbury Street
Boston MA 02203

For the fastest response from our office, please email or fax as physical mail has longer processing times.

Please only include email attachments as PDF's or JPEG's.

When you submit your inquiry please also prepare and submit the following documents:

A completed personal statement
Proof of Travel (Flight itinerary, hotel booking, etc.)
Relevant supporting documentation (death certificate, funeral/memorial service invitation, college tour confirmation, medical letter, employment letter, conference/award invitation, etc.).

If sending images, convert them into .pdf files by pasting them into a Word document. All proof must be in English.

Or you can download a Privacy Act Waiver form and fill it out yourself:

Privacy Act Waiver for non-immigration cases (English)
Spanish, Arabic, Chinese, Haitian Creole, Cape Verdean Creole, Khmer, Portuguese, Vietnamese

Once your form is filled out and signed with your original signature, please return it to my Boston office by doing one of the following:

Email: casework@warren.senate.gov

Fax: 202-228-4850

Mail:
Senator Elizabeth Warren
2400 JFK Federal Building
15 New Sudbury Street
Boston MA 02203

For the fastest response from our office, please email or fax as physical mail has longer processing times.

Please only include email attachments as PDF's or JPEG's.

Or you can download a Privacy Act Waiver form and fill it out yourself:

Once your form is filled out and signed with your wet ink signature, please return it to my Boston office by doing one of the following:

Email: casework@warren.senate.gov

Fax: 202-228-4850

Mail:
Senator Elizabeth Warren
2400 JFK Federal Building
15 New Sudbury Street
Boston MA 02203

For the fastest response from our office, please email or fax as physical mail has longer processing times.

Please only include email attachments as PDF's or JPEG's.

After you have read the statement above and downloaded the PDF, click "Confirm & Submit" button to finish.

Your Information

Have you Contacted

would you like

Would you like hidden fields

Do you currently

How can I Help?

-----IRS

-----Immigration, Citizenship, and Visas

Petitioner Information

Beneficiary Information

Additional Information

-----MEDICARE & MEDICAID

-----MEDICARE

-----MEDICAID

-----STUDENT LOAN

-----VETERANS

------Military

------Office of Personnel Management

------Passports

-------Social Security

-------General

-----FINISHING UP

PDF Signature

Certification Under Penalty of Perjury

Please Sign, Date and Send to our Office

Please download, sign, date, and send this form to our office.