Veterans Assistance

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This is only a preview of your Request.

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

If you would like to make any changes to the information you have provided, please use the "Edit" button below. Using your browser's buttons to navigate will cause all form information to be lost.

Your Contact Information
Case Details
Social Security No. format: XXX-XX-XXXX
Your Request
(please describe the problem in as much detail as necessary)

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

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.


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.