Passports

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Please confirm that all of the information below is correct, then click the Print and Submit button at the bottom of this page. When you click Print and Submit you will be directed to view or download a PDF document containing your information.

Please print the form, sign and date the last page, and return the form in its entirety by fax or by mail to:
Senator Chuck Schumer
780 Third Avenue Suite 2301
New York, NY 10017
Fax: (202) 228-2838

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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 *

Street Address (2)

City*

State*

Zip Code*

Do you have a different mailing address?

Case Details

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

Passport application locator number (if known)

Social Security No. *

Social Security No. format: XXX-XX-XXXX

Date of Birth *

Place of Birth

Date of Travel

First time application or renewal?*

Have you contacted another Congressional office?

Is this matter pending before a court of law?

Your Request

What do you need help with? *(please describe the problem in as much detail as necessary)

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

Preview and Print Privacy Release Form

Please click on the Preview button to review any information you have entered on this page.

Once you have reviewed your information on the next page, press the Print and Submit button. This will generate a PDF containing all of the information you have entered as well as a privacy release form. Please print the privacy release form, sign and date it, and return the form in its entirety by fax to (202) 228-2838 or via email to casework_schumer@schumer.senate.gov.

Although the information on your form will be submitted to our office electronically, most of the time we cannot open an inquiry on your behalf until we receive your signed form.

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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.