Production - JDC AOD Intake Form

JDC AOD Intake Form
Intake Date

MonthDayYear
Date
Informed the Intake participant

Informed: I am a volunteer attorney. I do not work for the government. I will not share any information with the DHS or Court without your consent. I will share this intake with the organization that runs this volunteer program, the Justice & Diversity Center, who will keep your information confidential.
Judge
AOD Name
AOD Email
example@example.com
Docket

Adult/familyFERMDedicatedJuvenile docket
MCH #

InitialReset, MCH#
Contact Name*

First NameLast Name
A#*
Birthdate*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
City
State
Zip Code
Gender
Ethnicity
Race
Country of Origin
Best Language
Other Language
Sexual Orientation
Disabled

YesNo
Disability Type
Education Level
Employment Status
Veteran?

YesNo
Household Size
Annual Household Income
Do you or does your child attend an SFUSD school?

YesNo
Pro Se Assistance Needed

Continuance to find counselChange of venueChange of addressConsolidate case with family membersFOIA request
Qualifies for

EAD ApplicationAnkle Monitor RemovalException to One Year Filing DeadlineMotion to Dismiss
EAD Clock Days
Asylum application filed?

YesNo
Date Filed?

MonthDayYear
Date
Advisal's and info provided to respondent

Change of address obligations and extra Form E-33 (required)Consequences of failure to appear (required)Court pro bono list (required) and JDC PacketNature of Proceedings & Right to an AttorneyChange of venueConsolidation
Next Hearing:

MasterIndividual
Next Hearing Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
FOLLOW-UP
Attorney Search
Contacted Attorneys?

YesNo
Who?
Circumstances prevented you from finding attorney (illness, etc.)?
Submitted docs to Court/ filed application/lodged asylum app?

YesNo
Which Documents?
Pleadings already taken?

YesNo
Applications pending before other agencies?

YesNo
Has Government Submitted Docs?

YesNo
What Type of Doc?
Date Motion or Doc Was Filed

MonthDayYear
Date
Date Response is Due

MonthDayYear
Date
IMM. HISTORY
First Entry Date

MonthDayYear
Date
First Entry Date Actions

EWIInspected/ParoledDetained/ Released
Last Entry Date

MonthDayYear
Date
Last Entry Date Actions

EWIInspected/ParoledDetained/ Released
NTA Charge(s)
NTA Service Date

MonthDayYear
Date
TYPE

Arriving AlienPresent w/o Admission
Admitted

Yes
Date Admitted

DayMonthYear
Date
Placement in Proceedings by:

ICECBP
Potential Suppression Claim

Advised
Immigration Arrest Location:
Current Immigration Status:
Total Entries:
Did you use the CBP One App prior to entering the U.S.?

YesNo
If No, and entered the U.S. after 5/11/23, then advise pro se about the CLP Rule.
If Yes, check if has I-94, when it expires, and if still valid, advise pro se about auto-eligibility for EAD.
Entered with family member?

YesNo
Consolidation of family members’ cases needed?

YesNo
A#'s
Absences from the U.S.?

YesNo
If Yes: DOE and DOD Dates not above:
Prior Immigration Contacts?

YesNo
If yes, explain:
Criminal History
Have you ever been arrested by the police here in the U.S. or in your home country?

YesNo
YEAR
COUNTY/STATE
ARREST / CHARGE (Offense)

MisdemeanorFelony
CONVICTION CODE
SENTENCE / SERVED
IMM. CONSEQ.
YEAR
COUNTY/STATE
ARREST / CHARGE (Offense)

MisdemeanorFelony
CONVICTION CODE
SENTENCE / SERVED
IMM. CONSEQ.
YEAR
COUNTY/STATE
ARREST / CHARGE (Offense)

MisdemeanorFelony
CONVICTION CODE
SENTENCE / SERVED
IMM. CONSEQ.
Family
Marital Status (include same-sex):
Spouse:

Has StatusNo status Location?
Riders
Number of Riders
Rider Name

First NameLast Name
A#
Date of Birth

MonthDayYear
Date
Gender
Relationship1
Rider Name

First NameLast Name
A#
Date of Birth

MonthDayYear
Date
Gender
Relationship
Rider Name

First NameLast Name
A#
Date of Birth

MonthDayYear
Date
Gender
Relationship
Rider Name

First NameLast Name
A#
Date of Birth

MonthDayYear
Date
Gender
Relationship
Rider Name

First NameLast Name
A#
Date of Birth

MonthDayYear
Date
Gender
Relationship
Children
Total # of Children:
No. in U.S.
With USC Status:
Ages
Parents
Parent Status

USCLPRNo statusOther
Other Parent Status
Grandparents
Grandparent Status

USCLPRNo statusOther
Other Grandparent Status
Siblings
Sibling Status

USCLPRNo statusOther
Other Siblings Status
Immigrant Petitions
Any Immigrant Petitions Filed for you? (Or for your spouse or parent)

YesNo
Possible 245(i) with details:

Yes
Petitioner
Type
Beneficiary
Date Filed

MonthDayYear
Date
Immigration Petition Status
U-Visa:
Have you/spouse/child/child’s sibling been a VICTIM of CRIME or DV in the US?

YesNo
If Yes, was it reported?

YesNo
Has copy of police report?

YesNo
Was Perpetrator found and charged?

YesNo
Law Enforcement Agency: (Which Police Dept/Court?)
Asylum/CAT/Withholding:
Fear of Return?

YesNo
Who are you afraid of?

Info Provided
PSG Fear Reason
Fear based on

RaceReligionPolitical OpNationalityPSGTorture
Intake Type
Reason/s for fear of return to Country of Origin:
Informed: I understand that it’s difficult to talk about traumatic events. However, you should know that if someone in your household physically, emotionally, or sexually harmed you, it could be a basis for asylum. Also if severely discriminated against or harmed because of LGBT status.
SIJS
Eligible?

YesNo
Do you live with your mother?

YesNo
Does she support you financially?

YesNo
Do you live with your father?

YesNo
Does he support you financially?

YesNo
Are you in contact with your parents?

YesNo
Advised: Better to apply before turning 18 but qualify until 21

Yes
T-Visa Eligibility
Did the people who helped you to enter the U.S. trick, pressure, intimidate, or scare you into to do something you were not comfortable doing? (i.e. carry something across a border)

YesNo
In the U.S. has anyone ever tricked, pressured, or intimidated you into doing something you were not comfortable doing, or forced you to work against your will?

YesNo
ALL RELIEF IDENTIFIED

AOSASYCATCitz ClaimSIJSLPR CORTPSNon-LPR CORT-VisaU-VisaWOR212(c)212(i)212(h)237(a)(1)(H)VAWA CORVAWA I-360 Self-PetitionOther
Other Relief

TPS Eligible? Check USCIS webpage for more information if pro se if from one of the following:

Afghanistan	Ethiopia	Nicaragua	South Sudan
Burma	Haiti	Syria	Ukraine
Cameroon	Honduras	Somalia	Venezuela
El Salvador	Nepal	Sudan	Yemen

Eligible for Deferred Action based on Labor Violation?
If 18 years or older:
Are you working?

YesNo
Has your employer paid you for all of the hours that you have worked?

YesNo
Were you ever sexually abused or harassed at work?

YesNo
Did you ever have to work in a condition that you felt was unsafe?

YesNo
If under 18 years of age:
Do you go to school?

YesNo
Are you also working?

YesNo
What type of work do you do?
Have you ever been injured at work?

YesNo
If Yes, what happened?
Legal Advice Provided:
Should be Empty:

JDC AOD Intake Form

FOLLOW-UP

Attorney Search

IMM. HISTORY

Criminal History

Family

Riders

Children

Parents

Grandparents

Siblings

Immigrant Petitions

U-Visa:

Asylum/CAT/Withholding:

SIJS

T-Visa Eligibility

Eligible for Deferred Action based on Labor Violation?

If 18 years or older:

If under 18 years of age: