Los Angeles District Office - Congressional Liaison Unit Inquiry Form

(Please print legibly in English and attach proof of filing)

 

Date of Inquiry

1st:

2nd:

3rd:

4th:

5th:

6th:

Follow-Up:

Congressional Office:

Staffer:

Telephone: (       ) 

FAX:          (       )

Applicant Information

Last Name:

 

First Name:

Middle Name:

A-File Number:

 

WAC Number:

Phone Number:

(        )

Other Names Used:

 

Check, if applicable:

 

Petitioner

 

Beneficiary

Date and Place of Birth:

Date and Place of Entry:                                                                                            Class of Admission:

Current Mailing Address:

 

 

Current Immigrant Status (check one)

 

 

U.S. Citizen

 

Permanent Resident

 

Refugee

 

Asylee

 

Undocumented

Type of Application

 

I-90       Replacement Alien Registration Card

 

I-539     Application to Change Status or Extend Stay

 

I-130     Immediate Relative Petition

 

I-589     Request for Asylum in the USA

 

I-131     Travel Document, Advance Parole

 

N-400    Application for Naturalization

 

I-140     Immigrant Petition for Foreign Worker

 

N-565    Replacement for Natz. or Citz. Certificate

 

I-212     Admission After Deportation or Removal

 

N-600    Certificate of Citizenship

 

I-485     Adjustment of  Status

 

Other:

 

I-506     Change of Non-Immigrant Classification

 

Other:

Date filed:

Have you been interviewed?

Yes             No                Date:                                     Where:

Additional Information

Attorney (if any):

 

Telephone: (         )

Outreach/Community Based Organization (CBO), if any:

Have you contacted your Senator or another Member of Congress?       Yes_______   No________

Member's Office:

If someone assisted you with this form, please provide their name and telephone number:

Name:                                                                                                                                           Telephone: (          )

Summary of Inquiry

 

 

 

 

Privacy Act Statement

Authority to collect this information is contained in Title 5 U.S.C. 552 and 552a.  The purpose of the collection is to enable

    the I.N.S. to locate applicable records and to respond to requests made under the Freedom of Information and Privacy Acts.

     I authorize the Congressional office named above to request information on my behalf.

________________________________________________________________                                     ______________________

                                                (Signature)                                                                                                                 (Date)

INS USE ONLY

Inquiry Number Assigned:

Related Inquiry Number (s)

Date Completed:

Method of Response:

Responsible Officer: