Form 1 Notice of Transfer to ICE Chief Counsel and Change of Ad

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services
OFFICE OF REFUGEE RESETTLEMENT
Division of Children’s Services
NOTICE OF TRANSFER TO ICE CHIEF COUNSEL - CHANGE OF ADDRESS/CHANGE OF VENUE

ORR has determined that the Juvenile Respondent named below should be transferred to another ORR funded facility. The
Director of the Office of Refugee Resetlement, U.S. Department of Health and Human Services requests that the Chief Counsel,
Immigration and Customs Enforcement, U.S. Department of Homeland Security, file a Motion for Change of Venue and/or
Change of Address with the Executive Office for Immigration Review for this minor.
Date of Request:

Request:

Name of Requestor

Title

Change of Address

¨

Change of Venue

Telephone Number

¨

I. CHANGE OF ADDRESS
1. Juvenile respondent biographical information
Name:

A#:

Aliases (if any):

DOB:

Country of Origin:
2. Juvenile respondent's originating address:
Originating ORR facility name (if applicable):
Street Address

City

Mailing Address (if different)

State

Zip

Telephone Number

State

Zip

State

Zip

Alternate Telephone #

3. Juvenile respondent's new address:
Receiving ORR facility name (if applicable):
Street Address

City

City

Mailing Address (if different)

State

Zip

Telephone Number

City

Alternate Telephone #

Receiving ORR facility point of contact:*
Point of Contact:

Point of Contact Title

Telephone Number

4. The Transfer is scheduled to take place on (date):
5. The next scheduled court apperearance for this juvenile is (date):

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to
average .20/hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services
6. For non-emergency transfers, notification should be made at least48 hours before the juvenile respondent is physically
transferred. If notification is not made at least 48 hours in advance of transfer, please explain reason(s) below:

* In cases where the child remains in an ORR funded facility, the facility staff is responsible for notifying the child of all
correspondence from the U.S. Department of Homeland Security (DHS) and for filing all DHS documents in the child's case file.

II. ChANGE OF VENUE (fill out only if alse requesting a Change of Venue)
7. Good cause exists to change venue in this matter pursuant to 8 C.F.R § 1003.20(b) for the following reason(s):

¨

Facility bed space in {insert facility} is limited. ORR has decided to relocate the respondent to an area where

¨

The minor has special needs (e.g., pregnancy of juvenile, medical needs, etc.), please specify:

¨

Juvenile respondent is suitable for a less restrictive level of care.

¨

Juvenile respondent requires a more restricted level of are.

¨

Other, please specify:

space is available/appropriate services can be provided.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to
average .20/hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, 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.