Intake Form

Name:
First Name *
Second Name
Surname
Second Surname
Current Address*:
Street (With house or apt #)
City *
State *
Postal Code *
Email Address:
Telephone No.*:
Work Phone No.:
Date of Birth*:
Place of Birth*:
City
Country
Your last level of education?
IMMIGRATION STATUS:
Do you have legal status in the US? *
Type of current legal status:
Date of last entry into the US:
How many entries have you made to the US?
"If you do not remember the exact date of entry and / or exit, please respond with an estimate (month and year)"
Are you afraid to return to your country?*
Yes ? Explain
Have you ever received public assistance?
Yes? Explain
Were you inspected (with passport, visa, etc.) on your last entry to the US? *
 
Type of visa at the last entry to the US:
Registration # or "A" #:
Country of birth: *
Country of your citizenship *:
Parents Information
 
Mother's Name
Father's Name:
Where do you work? (Name of job or place)*
Place
City
 
Work Position:
Since:
Have you ever been arrested from the police? *
 
If yes, how many times were you arrested?
 
For which offense:
 
For each offense:
 
When?
 
Where?
 
County or City
State
Country
Have you ever been in the deportation process? *
 
If yes, please explain (in which court, etc.):
Has an immigration petition ever been filed for your benefit?
 
If yes, please detail what type of request?
DEPENDENT INFORMATION:
Are you legally married? *
If yes, how many times have you been married?
If married, name of current spouse:
 
Spouse's Birthplace:
 
Immigration Status of Spouse in the US:
 
Place and Date of Marriage:
Place
Date
 
Nationality
 
Previous marriages?
For each child:
 
How many children do you have?
 
Mother's name:
 
Father's name:
 
Place of birth:
 
Date of birth:
Please write down your parents' information. If one or both are deceased, indicate the date of your death.
Your Mother - Date of Birth:
 
Her Birthplace:
 
Current Address (city / country):
City
State
Your Father - Date of Birth:
 
His Birthplace
 
Current Address (city / country):
City
State
Do you have other family members with legal status in the US (e.g. siblings)?
Are you afraid of returning to your home country?
(a) Have you ever been the victim of a crime? (b) The inclusion of domestic violence?
Name *
Signature *

Please be advised that I will proceed with the processing of your case based on the information provided in this data sheet. I assume that the information provided is accurate and complete. If there are any material changes with respect to the information you have provided on this form while your case is being processed by my office, it is your responsibility to notify me with respect to these changes. Failure to provide accurate and updated information may result in delays in processing your case and or denial of immigration benefits by U.S. Citizenship and Immigration Services.

Thank you. We look forward to assisting you with your case.

 
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