Special Immigrant Juvenile Status Referral Form

Special Immigrant Juvenile Status (SIJS) Referral Form

For Dependency Only
Dear Partners,

Below is the dedicated Special Immigrant Juvenile Status (SIJS) Referral Form. Please review the following information thoroughly before entering a submission.

For Dependency: LCYC will file the dependency petition (see a list of counties we serve below). After filing, LCYC will transition the case to a court appointed attorney, who will oversee the rest of the dependency proceedings. The immigration attorney must work with the court appointed attorney from that point forward in order to secure the Findings and Order Regarding Eligibility for Special Immigrant Juvenile Status (FOSIJS).

Eligibility: Dependency filings are limited to youths between the ages of 16 and 17.5 with stable housing at the time of referral (no exceptions on age).

Counties Served: LCYC files dependency petitions in these counties: Adams, Benton, Clark, Cowlitz, Franklin, Grant, Grays Harbor, King, Kittitas, Klickitat, Lewis, Mason, Pacific, Skagit, Skamania, Thurston, Walla Walla, and Yakima. Please check that your county is listed before making a referral.

For any inquiries or additional assistance with this form, please contact Taylor Faranda at Taylor@lcycwa.org
Date*

MonthDayYear
The SIJS Referral Form is dedicated to the following actions:*

Dependency

Immigration Attorney's Contact Information

Enter the contact information of the immigration attorney who will review documents from LCYC.
Immigration Attorney's name
Immigration Attorney's email
Immigration Attorney's phone number

Placement's Information

Who is the placement for the youth (where the youth will live and who will care for the youth)? Use this section to provide their information.
Placement's name

First NameMiddle NameLast Name
All known alias names used by placement? Please list them all.
What is the Placement's relationship to the youth?
Placement's date of birth.

MonthDayYear
Placement's phone number
Placement's email address
What language should we use when talking to the Placement?
Placement's address

Placement must reside in WA
Has anyone else ever had legal custody of the youth (Yes/No)? If "Yes," please provide their details in the box below (e.g., full name and contact information). Be sure to attach any relevant legal documents at the end of this referral form before submission.

Parents' Information

For Dependency, we have to serve the parents. Please provide contact information of the parents.
Mother's Information
Mother's name

First NameMiddle NameLast Name
All known alias names used by mother? Please list them all.
Enter the mother's date of birth

MonthDayYear
Mother's email address
Mother's phone number
Is the phone number above mother's WhatsApp number?

YesNo
Does the mother text?

YesNo
What language should we use when speaking to the mother?
Mother's address

Country
How to serve mother paperwork? If known, please provide the address or information below (e.g., by WhatsApp, by fax, the corner grocery store...etc.)
Other information about the mother (e.g., deceased? missing?...etc. Be sure to provide a date for each instance)
Father's Information
Father's name

First NameMiddle NameLast Name
All known alias names used by father? Please list them all.
Enter the father's date of birth

MonthDayYear
Father's email address
Father's phone number
Is the phone number above father's WhatsApp number?

YesNo
Does father text?

YesNo
What language should we speak when talking to the father?
Father's address

Country
How to serve father paperwork? If known, please provide the address or information below (e.g., by WhatsApp, by fax, the corner grocery store...etc.)
Other information about the father (e.g., deceased? missing?...etc. Be sure to provide a date for each instance)

Information on Household Individuals Age 18 or Over

LCYC will run a Washington Access to Criminal History (WATCH) report on anyone aged 18 or over living with the youth in the same household. Please provide information on each household individual aged 18 or over in the section below. Additionally, we need all known alias names for each person over the age of 18.
Individual 1

Enter additional information on anyone age 18 or over living in the same household as the youth.
Individual's name

First NameMiddle NameLast Name
Known alias names
Enter this individual's date of birth.

MonthDayYear
Individual 2

Enter additional information on anyone age 18 or over living in the same household as the youth.
Individual's name

First NameMiddle NameLast Name
Known alias names
Enter this individual's date of birth.

MonthDayYear
Individual 3

Enter additional information on anyone age 18 or over living in the same household as the youth.
Individual's name

First NameMiddle NameLast Name
Known alias names
Enter this individual's date of birth.

MonthDayYear
Individual 4

Enter additional information on anyone age 18 or over living in the same household as the youth.
Individual's name

First NameMiddle NameLast Name
Known alias names
Enter this individual's date of birth.

MonthDayYear
Individual 5

Enter additional information on anyone age 18 or over living in the same household as the youth.
Individual's name

First NameMiddle NameLast Name
Known alias names
Enter this individual's date of birth.

MonthDayYear
Please use the box below to list the full name (First, Middle, Last), date of birth (MM-DD-YY), and all known alias names for each additional individual aged 18 or older in the same household.

Birth Certificate and Immigration Attorney's Intake Notes
Please submit a copy of the youth's birth certificate with accompanying English translation in one document before submission. Please combine documents into one PDF.

Cancelof
Attach immigration attorney's initial intake notes here. Please combine documents into one PDF

Cancelof
Please attach any other documents we would need (e.g., Adoption Papers, Power of Attorney, Guardianship paperwork...etc.)

Cancelof
Use this space to enter any additional information not captured above.
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