Immigration Casework Intake Sheet printable pdf download

Immigration Casework Intake Sheet

Member of Congress: Doris Matsui

Petitioner/Applicant:

Name: _________________________________

Date Of Birth: _________________________

Alien number (if any): ____________________

Country of Birth: _______________________

Beneficiary:

Name: _________________________________

Date of Birth: _________________________

Alien number (if any): ____________________

Country of Birth: ______________________

* USCIS Receipt number/Tracking number: ________________________________________

Date of filing: _______________________

Place of filing: _______________________

Form type:

□ I-129 □ I-130 □ I-140 □ I-751 □ I-485 □ I-526 □ I-539 □ I-765 □ I-824

□ I-601 □ I-612 □ I-90 □ I-730 □ I-600A□ I-600 □ N-400 □ N-600 □ N-565

□ N-644 □ G-639 □ I-290B □ I-589 □I-590 □ I-131 □ I-131 □ Other:

Please include a brief description of the issue:

Staff Member: _______________________

Phone: 916-498-5600

Fax: 916-444-6117

Privacy Release: (To be completed by the individual who is the subject of the records.)

To remain in compliance with the Privacy Act as well as DHS policy and regulations, United States Citizenship and

Immigration Services (USCIS) may not disclose any information without written consent from the individual who is

the subject of the records. Family members, friends, an attorney, an authorized representative, or other

interested parties can not authorize the release of your personal information on your behalf.

I, ________________________________ grant Senator/Representative _____________________ and his or her

staff permission to receive and review any information contained in my USCIS electronic records or paper file.

Signature ____________________________________________ Date ________________

Immigration Casework Intake Sheet