Military/Department of Defense

If you are currently on active duty, I recommend that you first use your chain of command. If you have exhausted your chain of command, your home of record is Connecticut and you have not received a response, please fill out this online form and privacy release. Please print, sign and send the privacy release to my Hartford office. Once it is received, a member of my Constituent Services team will contact you to discuss how we can best help you resolve your issue. Please allow up to two weeks from the time we receive your privacy release for my office to contact you.

If your issue is time sensitive please contact my Hartford office at 860-258-6940.

Preview and Submit

This is a preview of your Request. Please confirm that all of the information below is correct before submitting. 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.

Primary Contact Info

Your Name

Title*
- First Name*
- Middle Name
- Last Name*
- Suffix

Your Contact Information

- Email *
- Verify Email *
Phone Number *
Secondary Phone Number
Street Address *
Street Address (2)
- City*
- State*
- Zip Code*

Federal Agency Information

Federal Agency Involved *
With which office is your claim pending?
Contacted another congressional office? *
- Which office?
- When?

Additional Information

Branch of Service *
Are you on active duty? *
Home of record *
Social Security No.
Social Security No. format: XXX-XX-XXXX
Date of Birth *
Rank
Unit/Duty Station
Military Serial No.
Please provide if you don't provide your social security number

Description of Request

Your Request

A brief statement of what has occurred and what you would like as a result of the Senator’s involvement. *(please describe the problem in as much detail as necessary)

Preview and Send Request

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 form, sign and date the last page, and return the form in its entirety to my Hartford office by fax or mail.

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

Edit

Preview

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.