Test New Casework Form

Please complete the privacy release form describing your problem, the federal agency involved and any other pertinent information related to your situation.

Once you have reviewed your information, press the Submit button. This will generate a printable version containing all of the information you have entered as well as a privacy release form.

Please print, sign, date and return the form in its entirety by fax or by mail to:

U.S. Senator John Boozman
213 West Monroe
Suite N
Lowell, AR 72745
Fax: (479) 725-0408

Please include any other documents or materials that you think would help my office help you. If you need the privacy release form mailed to you or if you have any questions about the form, please contact my Lowell office (479) 725-0400.

Before my office can begin an inquiry on your behalf, we must have a completed privacy release form with your signature to comply with the provisions of the Privacy Act.

To begin the process, please complete the following form.

Request Help With an Agency

Note: Fields marked with an * are required.

Your Information

Prefix *

First Name *

Middle Initial

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Home Phone *

Cell Phone

Email Address *

Date of Birth

Is this request being made on behalf of another individual? *

Other Individual Information

First Name

Middle Initial

Last Name

Address

Address 2

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Date of Birth

Request Information

What problem can I help with? *

Please provide a brief explanation of the problem *

Social Security Number

Civil Service Number (If you are a federal employee)

Veteran's Claim Number (If request relates to VA claim)

Alien Registration Number (If request relates to an immigration matter)

Branch of Service and Rank (If request relates to military service)

In accordance with the provisions of the Privacy Act, I hereby authorize Senator John Boozman or a member of his staff to make the appropriate inquiry about this issue on my behalf