REQUEST FOR ACCOMMODATION (Confidential)



REQUEST FOR AUXILIARY AID (CONFIDENTIAL)

KAJITOK IKIJEN MENIN JIBAN̄ (JEKJEK KO RETINO)

IUMIN TAITOL II kin RI-AMERICA RO ELON̄ UTAME KO ILO ENWBIN ACT, EINWŌT KEMLET

RA EO EDDOON JERBAL N̄AN ARMIJ

| |Ien Kajitok eo: |      |

|Jouj im Kokale Juon: | Et eo ilo Peba | Etan eo aikuij jiban̄ |

|Et eo etan Rikajitok: |      |

|Birokram/Makitkit ak jiban̄: |      |

|Ra eo Ejenolok/Kakobaba jen Kajojo/Juon |      |

|wāween Edik: | |

|Atreej eo kejerbal ikijen mails: |      |

|Talboon kejerbal ilo Raan: |      |

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|ABBLIKEJON |

|(Aikuij bwe kanne jen eo ej bok jiban̄/eo etan ebed ilo peba) |

|1. N̄a ij kajitok ikijen laajrak in menin jiban̄ in(kein): |      |

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|2. Aorok n̄an n̄a bwe in bok menin jiban̄ kein (ko) kin win kein rej laajrak: |

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|Eltan pein Rikajitok: | |Raan/Allōn̄/Iiō: | |

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|N̄an JERBAL KO WOT IJIN |

|KŌMMAN KARŌK |

|Kajitok in am kin |      |ikijen menin jiban̄ (ko) emoj an: |

| |(Ien eo Kajitok) | |

| |Tobrak |MENIN JIBAN̄ (KO) LILOK: |      |

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| |Jabtobrak |KWALOK UN (KO) KOMAN BWE ENJAB(TOBRAK): |      |

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| |Dedelok ilo Errā ekoba Kōmman Oktak n̄an |      |

| |Emanlok: | |

| |Errā ilo bojak n̄an Ron̄jake Ien Ekajet jen: |      |nan: |      |

| |Lemnak ko: |      |

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|Elan̄n̄e kojab errā kin Karok in, komaron̄ kwalok kakobaba melele ko n̄an juon ien tokelik n̄an etale kajitok in ilo am kirlok Geneva Watts, Civil |

|Rights Compliance Officer, ilo 586-4955 ak gwatts@dhs.. |

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