U.S. Department of Justice Executive Office for Immigration Review Office of the Chief Administrative Hearing Officer OMB#1125-0016 Unfair Immigration-Related Employment Practices Complaint Form Unfair Immigration-Related Employment Practices Complaint Form FORM INSTRUCTIONS Please read all of the directions carefully. Before you file a complaint with our office, you must have first: 1) Filed a charge with the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC), and 2) Received a letter from OSC telling you that you may now file your own complaint with the Office of the Chief Administrative Hearing Officer (OCAHO). Please note that your complaint must be filed with OCAHO within ninety (90) days of receiving the letter from OSC. If you need more space to respond to a question, you may attach additional sheets. Please indicate clearly which question(s) you are responding to on any additional sheets and number each additional sheet. If you complete this form by hand, please write using only blue or black ink. When you have completed the complaint, please return it, and the required documents below, to: United States Department of Justice Executive Office for Immigration Review Office of the Chief Administrative Hearing Officer 5107 Leesburg Pike, Suite 2519 Falls Church, VA 22041 CONTACT INFORMATION If you have any questions about this form, call OCAHO at 703-305-0864 (Mon.-Fri. 7:00am-4:00pm). If you need to contact OSC, call the OSC Worker Hotline at 1-800-255-7688 (toll free) or 1-800-237-2515 (TDD device for the hearing impaired), or write to: U.S. Department of Justice Civil Rights Division Office of Special Counsel for Immigration-Related Unfair Employment Practices 950 Pennsylvania Avenue, N.W. NYA 9000 Washington, DC 20530 For questions about Title VII of the Civil Rights Act of 1964, please contact the Equal Employment Opportunity Commission by calling 1-800-669-4000 (toll free) or 1-800-669-6820 (TDD device for the hearing impaired). Form EOIR-58 Revised Date: 05/22/2015 American LegalNet, Inc. www.FormsWorkFlow.com REQUIRED DOCUMENTS (You must include the following in the packet you mail to OCAHO): 1) Original complaint and four additional copies of your completed complaint, each with an original signature; and 2) Five copies of the charge document (and five copies of any attachments to the charge) you filed with OSC; and 3) Five copies of the letter you received from OSC telling you that you may now file your own complaint with OCAHO. Except for the original complaint, you should not send the originals of any other documents or attachments to OCAHO. A copy of the complaint and copies of all attachments will be sent by OCAHO to the Respondent Business/Employer once the complaint has been filed. Page 2 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Section 1: General Information 1) Please provide your name and contact information: Male Female (circle one) Full name (First Name) (Middle Name) (Last Name) Other names used Street Address City State Zip Code Home Phone Cell Number Email Address Fax Number 2) When did you file a charge with the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC)? ______/_______/___________ Month Day Year 3) When did you receive a letter from OSC telling you that you could now file your own complaint with the Office of the Chief Administrative Hearing Officer (OCAHO)? ______/_______/___________ Month Day Year Section 2: Representation Do you have an attorney or other authorized representative in this matter? _____YES or _____NO If YES, please provide the following information: Name of Representative Name of Business Street Address City State Zip Code Phone Number Email Address Fax Number Page 3 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Section 3a: Citizenship or Immigration Status at the Time of the Alleged Discrimination What was your citizenship or immigration status at the time of the alleged discrimination? United States Citizen or National or Alien Lawfully Admitted for Permanent Residence ("Green Card" Holder) or Alien authorized to work in the United States If you were a United States Citizen at the time of the alleged discrimination, go to Section 4. If you were not a United States Citizen at the time of the alleged discrimination, please complete this section. 1) Where were you born (country)? 2) What country were you a citizen of at the time of the alleged discrimination? __________________________________________ 3) If eligible to apply for naturalization, when did you become eligible to apply for naturalization? (If not yet eligible, leave this answer blank and go to question 5 below.) / Month Day / Year 4) Have you applied for naturalization? a) If YES, when did you apply? Month YES or / Day NO / Year 5) If you were a permanent resident (i.e., "Green Card" holder) at the time of the alleged discrimination, when did you obtain your permanent resident status? / Month Day / Year 6) If you were otherwise authorized to work in the United States at the time of the alleged discrimination, what was your citizenship status or visa type (e.g., asylee, refugee, Temporary Protected Status, H-1B, L-1, F-1, J-1, etc.)? _________________________________________________________________________ 7) What type of work authorization document did you possess at the time of the alleged discrimination? _________________________________________________________________________ Page 4 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Section 3a: Citizenship or Immigration Status at the Time of the Alleged Discrimination Continued 8) For what time period(s) (if any) were you authorized to work in the United States (to the present)? (If there were breaks in your work authorization, please attach a sheet listing all the time periods you were authorized to work in the United States.) From: Month / Day / Year To: Month / Day / Year I have never been authorized to work in the United States: ______ Section 3b: Current Citizenship or Immigration Status Information What is your current citizenship or immigration status? United States Citizen or National or Alien Lawfully Admitted for Permanent Residence ("Green Card" Holder) or Alien authorized to work in the United States or Alien who is not work authorized now, but who was authorized to work in the United States at the time of the alleged discrimination If you are a United States Citizen, go to Section 4. If you are not a United S