U.S. Congressman Pete Visclosky - Representing Indiana's 1st District

Fact Sheet

Print Out This Constituent Fact Sheet to Get Your Casework Started!

Congressman Pete Visclosky

Name:_______________________________________ Social Security Number:___________________

Address:_________________________________ City:____________________ Zip Code: ___________

Telphone (H):______________________ (W):______________________ Date of Birth: _____________

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)

Intial: ___ 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? Intial: ___ Claim Denied: ___ Appeal: ___ Board of Veteran Apeals: ___

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.

_____________________________________________________________________________________

You are requesting Congressman Visclosky to:

_____________________________________________________________________________________

PLEASE SIGN HERE -- CASEWORK CAN NOT BE INITIATED WITHOUT A SIGNATURE

Pursuant to the Privacy Act of 1974, I herby 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 <