Immigration & Citizenship Privacy Release Form

"*" indicates required fields

Contact Information

Prefix*

First Name*

Last Name*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Date of Birth*

Phone*

Country of Birth*

Alien Number (if any)

Receipt Number*

Date of Filing

Beneficiary Information

The address listed must match the mailing address submitted on the initial application.

Prefix

First Name

Last Name

Address

Street Address Address Line 2 City State ZIP Code

Enter Email Confirm Email

Date of Birth

Alien Number (if any)

Brief description of the issue*

Please print document and add your signature. You are welcomed to mail the document to the closest office, by email at Casework@cortezmasto.senate.gov, or by fax at 702-388-5030.

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Contact Information

Beneficiary Information

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