Fact Sheet 
Print Out This Constituent Fact Sheet to Get Your Casework Started! 
Congressman Pete Visclosky
Name:_______________________________________ Social Security Number:___________________ 
Date of Birth: _____________
Address:_________________________________ City:____________________ Zip Code: ___________ 
Telephone (H):______________________ (W):______________________ (C):______________________
Have you ever had a previous case with our office?______________ If yes, when?________________ 

Social Services Agency Information Section

Type of benefits applied for? (Check one) 
Social Security Retirement: ___ Social Security Disability: ___ Medicare: ___ Medicaid: ___ 
Welfare: ___ Workers Compensation ___ Equal Employment Opportunity Commission ___ 
Pension ___ Other ____________________ Date Filed:__________ 
At which office did you apply?___________________________________________ 
At what level is your claim? (Check one) 
Initial: ___ Hearing: ___ Claim denied and not re-opened: ___ Reconsideration: ___ 
Appeals Council: ___ Case Number? (If applicable) _________________________ 

Military/Veterans Affairs Information Section

Branch: Army: ___ Navy: ___ Air Force: ___ Marines: ___ National Guard: ___ 
Air National Guard: ___ Coast Guard: ___ 
Rank, Social Security Number, or Service Number:__________________________________ 
Entry Date:___________________________________ Discharge Date:________________________ 
Unit:______________________________________________________________________________ 
VA Claim Number:_____________________ Type of VA Benefit applied for:_____________ 
At what level is your claim? Initial: ___ Claim Denied: ___ Appeal: ___ Board of Veteran Appeals: ___ 

Immigration Section

Alien Number? _________________________ Type of Application? __________________________ 
Date of Receipt? ___________________________ Date of Interview? __________________________ 
Check All Applicable Problems: 
Previous Inquiry Attached: ___ Green Card: ___ Interviews: ___ Oath Ceremony: ___ Fingerprints: ___ 
Rescheduled Interview: ___ Rescheduled Oath: ___ Fee Receipts: ___ 
Employment Authorization (EAD): ___ File Lost/Transfer: ___ Others: __________________________ 
PLEASE PRINT LEGIBLY USING BLACK INK 
Please describe your problem and include any relevant file, claim, alien registration, or identification
numbers and the phone numbers of individuals with whom you have previously discussed the problem. 
If possible, please provide copies of documentation that may help with your case. If you need more 
space, please continue on another sheet of paper.
 
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You are requesting Congressman Visclosky to: 
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PLEASE SIGN HERE -- CASEWORK CAN NOT BE INITIATED WITHOUT A SIGNATURE 

Pursuant to the Privacy Act of 1974, I hereby give Congressman Pete Visclosky, as well as his staff,
permission to contact and obtain any information necessary to assist me. 
Signature:______________________________________________ Date:_________________ 

Mail to: 
Congressman Pete Visclosky 
7895 Broadway, Suite A 
Merrillville, IN 46410
Phone: 219-795-1844
Fax to: 219-795-1850