Form 1 Request for Specific Consent

US Department of Health and Human Services Request for Specific Consent to Juvenile Court Jurisdiction

OFFICE OF REFUGEE RESETTLEMENT

Division of Unaccompanied Children’s Services

Please submit this Request for Specific Consent to Juvenile Court Jurisdiction 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 Office of Refugee Resettlement 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 marketed “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. The request for reconsideration should be sent to: Assistant Secretary, Administration for Children and Families, 370 L’Enfant Promenade. 6^th Floor, Washington, DC, 20447, ATTENTION: SIJ Specific Consent Reconsideration.

• The ACF Assistant Secretary will send his/her decision on the reconsideration to the Attorney of Record or other individual or entity authorized to act for the child within fifteen business days from the date of the receipt of the reconsideration request. This will be considered a final administrative decision.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden of this collection of information is estimated to average 0.333 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to DHHS/ACF Reports Clearance Officer; 370 L’Enfant Promenade, S.W.; Washington, D.C. 20447

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Request for Specific Consent to Juvenile Court Jurisdiction, 03/31/2011

ORR C-1

OMB 0970-0385, valid through 03/31/2014