Form 1 Interim Request for Specific Consent to Juvenile Court J

INTERIM REQUEST FOR SPECIFIC CONSENT TO

JUVENILE COURT JURISDICTION

Please submit this Interim Request for Specific Consent electronically to [email protected]

DATE OF REQUEST FOR CONSENT
SUBMISSION BY: NAME TITLE ORGANIZATION TELEPHONE FACSIMILE EMAIL
CASE PRIORITY: NORMAL URGENT	If the case is urgent, please explain here:

SECTION 1: BASIC DATA OF UNACCOMPANIED ALIEN CHILD

FULL NAME
ALIAS
ALIEN NUMBER
DATE OF BIRTH
PLACE OF BIRTH
CURRENT ADDRESS (Name of HHS-funded facility or program)
SCHEDULED STATE OR IMMIGRATION COURT HEARING RELEVANT TO REQUEST	Please provide date, city, and state:

SECTION 2: REQUEST FOR SPECIFIC CONSENT TO JUVENILE COURT JURISDICTION TO DETERMINE CUSTODY STATUS OR PLACEMENT

REQUIRED: Please attach a G-28, EOIR-28 or EOIR-29, or other form of authorization to act on behalf of the unaccompanied alien child.

• I am seeking a change in custody status or placement on behalf of the unaccompanied alien child.

Please provide a brief statement below concerning the reasons for this request to change custody status or placement.

Signature

Print Complete Name

NEXT STEPS:

• The U.S. Department of Health and Human Services will electronically acknowledge receipt of this request in no more than two business days to the email listed herein, and will provide a decision within thirty business days, unless the request is marked “urgent.”

• In the event the request is denied, the Attorney of Record or other individual or entity authorized to act for the child will have thirty business days from the date of receipt of the denial to submit a request for reconsideration. Policy guidance concerning the reconsideration process will be issued shortly.

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