Veterans

An inquiry can be made regarding the status of a claim for service-connected disability, payment of education benefits, medical care at VA facilities, or other problems. In order to assist a veteran with personal issues involving the U.S. Department of Veterans Affairs (VA), Senator Durbin must, by law, have a Privacy Act Release Form signed by the veteran or a friend or family member who has power-of-attorney.

Constituents may reach out to my office for casework assistance via my webpage or phone. Visitors to my office must have a scheduled appointment in order to meet with my staff.

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?

Case Details

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

Claimant's Social Security No.*

Social Security No. format: XXX-XX-XXXX

Are you currently working with a Veterans Service Officer? *

Type of Veterans Benefits Sought: *

Claim Number, Registration Number, or Other Identifying Information:

Congressional Contact

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 certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy release and any document submitted with it; 2) I reviewed and understand all of the information contained in my privacy release and submitted with it; and 3) all of this information is complete, true, and correct. *

* The VA 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.

Preparing PDF...

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

Veterans

Preview and Send Request

Preparing PDF...