Application For Extension Of Time To File U.s. Income Tax Return - Application For Extension Of Time To File U.s. Income Tax Return Page 2

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U.S. Department of Justice
Office of Special Counsel for Immigration-Related Unfair Employment Practices
Referral Transmittal Information Sheet
Name of Referring Agency:
City, State:
Matter Name Used By Your Agency:
Case No. Assigned By Your Agency:
Date Filed:
Discrimination Date:
Charging Party’s Primary Language:
Name of Assigned Attorney/Investigator:
Telephone Number:
E-Mail Address:
Will your agency continue to investigate any aspect of this charge?
Yes
No
If "Yes," identify what aspects of the charge remains under investigation by your agency:
Has the Charging Party filed a parallel charge with another agency?
Yes
No
If "Yes," identify the agency receiving parallel
City, State:
Case Number, if known:
charge:
Point of Contact, if
Date Filed, if known:
known:
Has all or part of this charge been referred to another agency?
Yes
No
If "Yes," identify the office/agency that received the
City, State:
Case Number, if known:
referral and the nature of the referral:
Point of Contact, if
Date referred:
known:
Accompanying Documents:
Agency intake
Charging Party
Respondent
Other, specify
documents
submissions
submissions
below
Description of Additional Documents Enclosed:
Comments:

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