Privacy Release Form

Constituent Information

Please fill out the information below for the constituent who needs assistance.

Prefix*

First Name *

Last Name *

Street Address *

Street Address (2)

City *

State *

Zip Code *

E-mail *

Verify E-mail *

Home Phone

Cell Phone

Date Of Birth*

Case Information I am filing on behalf of someone else as their legally-appointed guardian or representative.

Please provide the name and address of the legally-appointed guardian or representative.

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Street Address *

Street Address (2)

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State *

Zip Code *

Yes, I would like to receive U.S. Senator Joe Donnelly's Electronic Newsletter

If applicable, please provide the following information:

Social Security Number:

Branch Of Service:

How did you hear about my office?

Your Request:

I request U.S. Senator Joe Donnelly to: *

Constituent Authorization

I am aware that the Privacy Act of 1974 prohibits the release of my personal information without my expressed, written consent. I hereby authorize U.S. Senator Joe Donnelly, or a staff representative designated by him, to inquire on my behalf to all appropriate agencies and organizations.

Request must be signed by involved constituent or legally-appointed guardian or representative.

Clicking the button below generate a pdf document which you must print, sign,and return to U.S. Senator Joe Donnelly’s office:

115 N. Pennsylvania Street, Suite 100,
Indianapolis, Indiana 46204.
Phone: (317) 226-5555,
Fax: (855) 772-7518.

Things You Should Know

Note: you must have already filed an application, petition, formal complaint or otherwise contacted the federal agency in writing before Joe's office can intervene on your behalf.

Unfortunately, Joe's office cannot help you if your problem is with a state or local agency, or if it is a judicial or civil matter before the courts. Examples of local & state issues include:

Unemployment benefits
Medicaid/food stamps
Lost driver's license
Police and criminal investigations

For any of the above problems, please contact the appropriate state or local official. You can find out who your state representatives are by typing in your zip code at the Indiana General Assembly website.

Because of the constitutional separation of powers, judicial matters (matters before the courts) do not fall under Joe's jurisdiction as a U.S. Senator. Examples of judicial matters include:

Deportation proceedings or any matter before immigration courts
Divorce, child custody or other civil disputes
Criminal trials

Joe cannot act as an attorney or offer legal assistance in any way. Note that while Joe's office will make its best efforts to assist you, please remember that federal agencies have discretion concerning decisions on individual cases and have the final say on the outcome.

U.S. Senator Joe Donnelly of Indiana

Privacy Release Form

Evansville, Indiana

Fort Wayne, Indiana

Hammond, Indiana

Indianapolis, Indiana

Jeffersonville, Indiana

South Bend, Indiana

WASHINGTON, D.C.