General Casework

Your Contact Information

Title*

First Name*

Middle Name

Last Name*

Suffix

Gender

Date of Birth

Email Address

Please Verify Email Address

Phone Number *

Home, work, mobile, other.

Secondary Phone Number

Home, work, mobile, other.

Street Address or P.O. Box*

Street Address (2)

City*

County of Residence *

State*

Zip Code*

Do you have a different mailing address?

Additional Information

Which government agency (or agencies) have you been working with? *

Claimant's Social Security No.

Social Security No. format: XXX-XX-XXXX

Have you contacted another Congressional office? *

Your Request

What do you need help with? *

Please describe the problem in as much detail as necessary.

Is there anything else that Senator Durbin or his staff needs to know?

I am filling out this form for myself only, not family, friends, or others. *

I attest to the truthfulness of the information contained in this form. *

* If the Power of Attorney is making the inquiry please fax a copy of the Power of Attorney to the D.C. office.

* The SSA does not recognize Power of Attorney.

* Medal requests should be requested by Veterans, or if deceased, next of kin.

Preview and Send Request

Once you have reviewed your information, press the Print Privacy Release Form button. This will generate a PDF containing all of the information you have entered as well as a privacy release form. Please print the form, sign and date the last page, and return the form in its entirety to the Senator's office by fax or mail.

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Thank you for contacting me. The information on your form has been submitted electronically to my office. A PDF of your form is being generated automatically and should be ready within 10 seconds. If one is not available to download in that time, click here.

Once we have received your signed authorization, my staff will begin assessing how we can help. Please allow up to 30 days from the day we receive your release for my office to contact you. Thank you.

Senator Dick Durbin

General Casework

Preview and Send Request

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