Fillable USCIS-OLA-Privacy-Release-Oct-2019 Immigration Casework In-Take Sheet

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USCIS-OLA-Privacy-Release-Oct-2019 Immigration Casework In-Take Sheet

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The USCIS-OLA-Privacy-Release-Oct-2019 Immigration Casework In-Take Sheet form is 2 pages long and contains:

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  • 35 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Privacy Release
Version 10/17/19 1
Member of Congress:
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 or tracking number (no Social Security numbers):
Date of filing:
Form type(s) – check all that apply:
G-639 I-90 I-129 I-129F I-130 I-131 I-140 I-212 I-290B I-360
I-485 I-526 I-539 I-589 I-590 I-600A I-600 I-601 I-612 I-690
I-730 I-751 I-765 I-821 I-824 I-829 I-914 (Supplement A, B, or C)
I-918 I-924 I-929 N-400 N-600 N-565 N-644 Other:
Privacy Release
Version 10/17/19 2
Brief description of the issue (if you need more space, attach a separate sheet):
Staff Member (print): Phone:
Email:
Section below to be completed by the person who is the subject of the records:
I certify, under penalty of perjury, that 1) I provided or authorized all of the information in this privacy
release and any document submitted with it; 2) I reviewed and understand all of the information contained
in my privacy release and submitted with it; and 3) all of this information is complete, true, and correct.
I, (print your name) , authorize USCIS to release
information contained in my USCIS records as relevant to checking my case status, and to the extent
permitted by law, to Senator/Representative and the Member’s staff.
Signature (sign in ink): Date:
Current Residential Address (Do not list a P.O. Box.)
Address:
Phone: Email:
Mailing Address (If different from current residential address, i.e., P.O. Box.)
Address:
Phone: Email:
T
ranslator Certification (If privacy release or any of the supplemental information has been
translated.)
I certify, under penalty of perjury, that I am fluent in English and _______________, and that my
translation of the privacy release and any foreign language documents submitted with this inquiry are
complete and accurate.
Translator Name (print): ______________________
Signature (sign in ink): Date:
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USCIS-OLA-Privacy-Release-Oct-2019 Immigration Casework In-Take Sheet

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Completed 5 April 2020

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