What is your full name?

Email Address

Whats is your telephone/cellphone number?

When did you first enter the US?

When was the last time?

How did you enter the last time? How did you enter the last time? Visa No documentation/Not inspected Border checkpoint Other

List all entries and exits from the USA (please indicate full dates and whether or not you went an immigration inspection at these entries, and if so, when your authorization to remain expired)

What problems brought you to this office?

Have you ever been ordered removed or deported from the US? Have you ever been ordered removed or deported from the US? Yes No

Have you ever been to immigration court? Have you ever been to immigration court? Yes No

Have you ever been stopped by immigration officials? Have you ever been stopped by immigration officials? Yes No

If yes, to any of the options above, please describe:

Have you ever applied for any immigration benefits? (Permanent residency, asylum, TPS, cancellation, suspension, Deferred Action for Childhood Arrivals [DACA], visa application, or any other immigration benefit). Have you ever applied for any immigration benefits? (Permanent residency, asylum, TPS, cancellation, suspension, Deferred Action for Childhood Arrivals [DACA], visa application, or any other immigration benefit). Yes No

If so, please let us know when and what types of paperwork: What was the result?

Any paperwork filed in your name? (Family visa application?) Any paperwork filed in your name? (Family visa application?) Yes No

Were your parents or grandparents US citizens? Were your parents or grandparents US citizens? Yes No

Are you married? Are you married? Yes No

If yes, please provide your spouse's name, your spouse's immigration status, and the date and location of your marriage:

Do you have children? Do you have children? Yes No

If yes, please provide the information: Name, date and place of birth, immigration status and whether you are in the US now.

Do you have other family members in the US? Do you have other family members in the US? Yes No

If yes, list name, relationship and immigration status.

Have you ever had problems with the police or been arrested in the USA? Have you ever had problems with the police or been arrested in the USA? Yes No

If yes, when and why?

Have you ever been stopped by immigration authorities? Have you ever been stopped by immigration authorities? Yes No

Have you ever been stopped by a law enforcement officer? Exclude simple traffic stops. Have you ever been stopped by a law enforcement officer? Exclude simple traffic stops. Yes No

Have you ever been in front of a judge? Have you ever been in front of a judge? Yes No

Have you ever had an immigration lawyer represent you? Have you ever had an immigration lawyer represent you? Yes No

Have you ever signed an immigration form? Have you ever signed an immigration form? Yes No

Have you ever had your fingerprints taken? Have you ever had your fingerprints taken? Yes No

Have you ever helped someone come to the United States without documents? Have you ever helped someone come to the United States without documents? Yes No

Have you ever used false documents to come to the United States? Have you ever used false documents to come to the United States? Yes No

Have you ever claimed to be a US citizen? Have you ever claimed to be a US citizen? Yes No

Have you ever lied or hidden the truth to obtain a visa or enter the United States? Have you ever lied or hidden the truth to obtain a visa or enter the United States? Yes No

Do you have any reason to fear returning to your country? Do you have any reason to fear returning to your country? Yes No

Have you ever been a victim of domestic abuse by a spouse, parent or child? Have you ever been a victim of domestic abuse by a spouse, parent or child? Yes No

Have you ever been threatened or harmed by a spouse, parent or child? Have you ever been threatened or harmed by a spouse, parent or child? Yes No

If so, did your spouse, parent, or child have U.S. citizenship status or legal permanent residency? If so, did your spouse, parent, or child have U.S. citizenship status or legal permanent residency? Yes No

Have you ever been a victim of a crime? Have you ever been a victim of a crime? Yes No

If yes, please state what crime and whether you reported it to the police and/or helped with the criminal investigation or prosecution.

Did someone recruit you in your home country to work in the United States? Did someone recruit you in your home country to work in the United States? Yes No

Did you feel forced to work or were you tricked into working? Did you feel forced to work or were you tricked into working? Yes No

Were you forced to work without pay? (or less salary than allowed or expected)? Were you forced to work without pay? (or less salary than allowed or expected)? Yes No

Were you abandoned, abused, or neglected by your parents? Were you abandoned, abused, or neglected by your parents? Yes No

Are you currently under the jurisdiction of a juvenile court (dependency, delinquency or guardianship)? Are you currently under the jurisdiction of a juvenile court (dependency, delinquency or guardianship)? Yes No