ILSA's Inc. Immigration Intake Form - Immigration Law & Social Advocacy Services, Inc. ilsa-inc.online

Current Date

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Referred by:

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First Name

Enter your first name as shown on your passport.

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Last Name

Enter your last name as shown on your passport.

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Nationality:

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Date of Birth

month/date/Year( mm/dd/yyyy)

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Place of Birth

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Email Address

Enter a valid email address where we can contact you.

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Cell Phone Number

Enter your phone number with country code.

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Other Phone Number

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Address

Your current residential address.

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

Immigration Status

Select your current immigration status.

Citizen

Permanent Resident

Visitor

Student Visa

Other

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Reason for Application

Briefly describe the reason for your immigration application.

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GDPR Compliance

You must agree to the GDPR compliance to proceed.

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Immigration History
1a. When did you first enter the U.S.? :

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1b. When was the last time?:

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2. How did you enter the last time?

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VISA

Check if applicable

No papers, but at a checkpoint:

Check if applicable

Not inspected/other:

Check if applicable and describe below

IF Not inspected/other describe:

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3. List all entries to and exits from the U.S. (Give dates, and whether or not you went through
an immigration inspection upon those entries.)

A. Entry,
B. Exit,
C. Inspected by Immigration authorities (which, Yes or No)
D. If, yes, what status (visa) did you have on entry
E. When did the authorized status expire?
(Make a copy of any visas and I-94s)

4a. What problems have brought you here to this office? 4b. What do you hope that the attorney/ advocate can do about those problems?

5. Have you ever been ordered removed or deported from the U.S.? Yes/No

6. Have you ever been in immigration court? Yes/No

7. Have you ever been stopped by immigration officials? Yes/No

7a. If yes to any of the above, please describe

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8. Have you ever applied for any immigration benefit? (Examples: Permanent residency, asylum, amnesty, TPS, cancellation, suspension, Family Unity, DACA, visa petition, U visa, T visa, SIJS, or any other immigration benefit). If so, please tell us when and what types of paperwork:_________________(describe below)
What was the result? _____________(describe below)

9. Has any paperwork been filed on your behalf? (Visa petition by family?) Yes/No

FAMILY:
10. Were your parent(s) or your grandparents U.S. citizens? Yes/No

11. Are you married? Yes/No

11b. When and where? ______
Name of spouse, status, date married: _________
Name of previous spouse, status, and date marriage ended: _______________

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12. Do you have children? If so, provide the following information: Yes/No

12a. If so, provide the following information:
Children’s names, Date, and Place of Birth, and Immigration status in the U.S. now?

13. Do you have any other family members in the U.S.? Yes/No

13a. If Yes, please provide their Names, relation, Immigration status, and if they are in U.S. now?

14. Employment in U.S. — Dates and types of employment, name & address of employer:

Name of Employer
Address of Employer
Type of Employment
Period of Employment
Work authorized

15. Have you ever had trouble with the police or been arrested in the U.S.? If so when and for what? What sentence did you receive?

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16. Do you have any reason to fear going back to your country? Who do you fear and why?

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

18. 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 lawful permanent residency?

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19. Have you ever been the victim of a crime? Yes/No

If so, what crime?

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If so, did you report it to the police or help with the criminal investigation or
prosecution? Yes/No

20. Did anyone recruit you in your home country to work in the United States? Yes/No

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

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

21. Have you been abandoned, abused, or neglected by a parent? Yes/No

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

ILSA’s Inc. Immigration Intake Form