Social Security Privacy Release Form

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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*

Social Security Number*

Social Security Information

What type of SSA benefits are you inquiring on?*

Claim/Reference number*

Is this matter pending before a court of law or Administrative Law Judge?*

Brief description of the issue*

Please review all the information above carefully before submitting. Once you sign and date below, please hit the "submit" button below, then again on the confirmation page so my office can begin assisting you.

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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