Intake Form – Immigration Law

Step 1 of 8

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Name:

First Last

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Home):

Phone (Work/Cell):

Email:

Place of Current Employment:

Date of Birth:

MM slash DD slash YYYY

Place of Birth:

Current Immigration Status:

Immigration Number (A#):

When did you obtain LPR status?

How did you obtain LPR status?

Spouse's Name:

First Last

Spouse's Date of Birth:

MM slash DD slash YYYY

Spouse's Current Status:

Date of Marriage:

Place of Marriage:

Children:

Name

Date of Birth

Place of Birth

Immigration Status

Family members that served in the US Military:

Name

Relationship

Branch

Date of Service

Intake Questions

1. Have you or your spouse ever been married previously?*

Yes

1(a). Please enter that information.

Name

Date of Marriage

Date of Dissolution

2. Where was your mother born?*

3. Where was your father born?*

4. Did either of your parents ever become United States Citizens?*

Yes

4(a). When?

5. Were any of your grandparents born in the United States?*

Yes

5(a). When & Where?

6. Are any of your siblings United States Citizens?*

Yes

6(a). Who?

7. Have you ever, verbally or in writing, claimed to be a United States Citizen?*

Yes

8. Date of Entry to the United States

Date

Place

How?

9. Date of Exit from the United States

Date

10. How long have you lived in the United States?

11. How old were you when you began to live in the United States?

12. Schools Attended

School

Location

Date Attended

13. Did you obtain a GED or diploma?*

Yes

13(a). When?

14. Have you ever filed any applications with the USCIS?*

Yes

14(a). What type of application? When did you file? Where did you file? Who filled out the forms? Was it granted or denied?

15. Have you ever been arrested by USCIS?*

Yes

15(a). When and where?

16. Have you ever been in deportation proceedings or seen an Immigration Judge?*

Yes

17. Have you ever been deported, removed, excluded, or voluntarily returned from the United States by the USCIS?*

Yes

17(a). How many times? When and where?

18. Have you been arrested by any police in any country? (Examples: DWI, PI, Driving without a license, assault, no insurance, domestic violence, robbery, etc.)*

Yes

18(a). Please enter that information.

Date

Place

Sentence

19. Were you in the United States on December 21, 2000?*

Yes

20. Were you in the United States on June 15, 2012?*

Yes

21. Have you ever had any other immigration status or visa?*

Yes

21(a). When?

22. Have you ever had a visa cancelled or taken away by the USCIS?*

Yes

22(a). When and where?

23. Do you fear returning to your native country?*

Yes

23(a). Why? Please give details of the reasons & the incidents that may have happened to you or your family.

24. If your spouse is a United States citizen or Lawful Permanent Resident, does he or she have any criminal history?*

Yes

24(a). Please enter that information.

Date

Place

Sentence

25. Have you ever been abused, either verbally or physically your US Citizen or Lawful Permanent Resident spouse?*

Yes

25(a). Please describe the incidents.

26. Have you ever been a victim of any type of crime?*

Yes

26(a). Please describe the incidents.

27. Have you ever registered for Selective Service?*

Yes

27(a). Please provide your number.

28. Have you ever filed federal income tax returns?*

Yes

28(a). Which years?

29. Briefly describe the reason for contacting our office?*

30. How were you referred to our office?

Contact Name*

First Last

Contact Phone*

Relationship (if any)*

Email*

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Name

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