Immigration Casework Form – Fill Out and Use This PDF

Immigration Casework Intake Sheet

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/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: _________________________

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 ________________