Online Request Authorization Form

1 Current: Print Form
2 Complete

First

Last

Email Address

Phone Number

Address

Address 2

City

ZIP Code

County

Date of Birth

Federal Agency Involved

Veteran's Claim Number

Military Branch of Service

Military Rank

Alien Registration Number

On Behalf of Family Member

If you are requesting assistance on behalf of a family member, please provide that person's name. Please be aware that Senator Portman can only act with that person's permission.

Other Office Contacted

If you have contacted another congressional office regarding this issue, please list the office.

Detailed Description of Problem

Online Request Authorization Form

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