Language
English (US)
Spanish (Latin America)
Deportation Defense Questionnaire
A. Person providing information (if different from the person detained or in immigration proceedings)
Full Name
*
First Name
Last Name
Phone Number
*
Relationship
*
Languages Spoken
B. Identifying information about the person detained or in immigration proceedings
Full Name
*
Prefix
First Name
Middle Name
Last Name
Alias, Nickname, or Other Name(s) S/he Goes By
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
A Number
Booking Number
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Place of Birth (City & State)
Country of Citizenship
*
C. Access to counsel
Are you working with an immigration attorney on your case?
*
Yes
No
If yes, name and phone number?
If no, have you worked with a private immigration attorney in the past?
Yes
No
Can you afford a private attorney now?
Yes
No
Are you working with a criminal attorney on your case?
Yes
No
If yes, name and phone number?
D. Actions that led to immigration proceedings
When were you placed in ICE custody?
*
/
Month
/
Day
Year
Date Picker Icon
From where were you arrested or detained by ICE?
*
Please Select
Home
Workplace
Jail or other Detention Facility
Other
Provide description of where you were arrested
*
Please describe in detail how you were put in immigration detention or in proceedings [this time]:
*
When were you put in deportation proceedings?
/
Month
/
Day
Year
Date Picker Icon
Where are you currently being held, if currently detained?
E. Legal proceedings
Do you have a scheduled court date or other deadline?
*
Yes
No
If yes, please provide the date
/
Month
/
Day
Year
Date Picker Icon
If yes, describe what type of deadline
Do you have a “voluntary departure” or deportation date?
*
Yes
No
If yes, what date?
/
Month
/
Day
Year
Date Picker Icon
Have you seen an immigration judge since being in detention?
Yes
No
If yes, what date did you see the judge?
/
Month
/
Day
Year
Date Picker Icon
Have you requested more time from the judge?
*
Yes
No
Have you filed any legal motions?
*
Yes
No
If yes, list type of motion, date filed, and decision received.
Have you received any final order?:
*
Yes
No
If yes, list date, location and details
Were you given a copy of the Notice to Appear?
*
Yes
No
If yes, please write the factual and legal allegations written on the Notice to Appear
F. Immigration History
When did you first enter the U.S. (month and year)?
*
/
Month
/
Day
Year
Date Picker Icon
How did you first enter the U.S.?
*
Please Select
With documentation
Crossed the border
If with documentation, type of visa and date of expiry?
If across border, did you get stopped by border patrol at any point?
Do you currently have legal status?
*
Yes
No
Other
If yes, please indicate type (Greencard/LPR/Other) AND date received
If other, please explain
Have you ever left the U.S. since you first entered?
*
Yes
No
If yes, date(s) left and for how long
When was your most recent entry Into U.S.? (if different than above)
/
Month
/
Day
Year
Date Picker Icon
Since you came to the U.S. have you had any other contact with border patrol or immigration agents?
Yes
No
Have you ever been deported or ordered deported?
*
Yes
No
If yes, please give us details and dates.
Have you ever tried to change your immigration status (asking for political asylum, or through a relative or employer petition)?
*
Yes
No
If yes, what was the result?
G. Police Enforcement History
Before your recent detention by immigration enforcement, were you in contact with the local police, the courts, or your probation office?
*
Yes
No
If yes, provide details
Have you ever been arrested by local police?
*
Yes
No
If yes, have you ever been charged, or convicted of any offense? Have you ever been convicted or charged with identity theft or using fake documents? Have you ever been arrested or stopped for driving under the influence of drugs or alcohol? If so, please tell us as many details as you can.
Have you pled guilty for any of these charges?
*
Yes
No
Not Applicable
If yes, did your lawyer or the judge tell you that there were immigration consequences for your plea?
Lawyer
Judge
Other
Have you ever been arrested or charged with a crime in another country?
Yes
No
H. Family History
Are you married or have a partner who is a U.S. citizen or resident?
*
Yes
No
Do you have any children?
*
Yes
No
If yes, how many and what are their ages?
What is their immigration status?
Do they live with you?
Yes
No
Do you support them?
Yes
No
Is there anyone else in your family for whom you are responsible for?
*
Do you have any other relatives that are U.S. citizens or residents?
*
Do your children or other close relatives have medical or special needs that you are responsible for?
*
Do any of your family members rely heavily upon you to survive – Physically? Economically?
*
Yes
No
Name and contact info for at least one family/friend outside of jail:
*
I. Other Important Information
What kind of work did/do you do? Where? For how long?
*
Are you a member of a local community organization? Do you volunteer with any community organization, group or church? What do you do? Have you ever been involved in a fight for labor rights, civil rights, housing rights, human rights or other community organizations?
*
Have you ever been to school in the U.S.? If so, what was the highest level achieved?
*
Are you a survivor of domestic violence? Did you report it to the police?
*
Are you scared of returning to your country? Do you know if you face danger when you return?
*
Yes
No
If potential asylum claim: Have you been a victim of physical abuse, imprisonment, or torture in your home country? Please describe.
If potential asylum claim: Have any of your family members ever been victims of physical abuse, imprisonment or torture in your home country? If yes, please describe in detail.
If potential asylum claim: Do you think you will be a victim of physical abuse, imprisonment or torture if you are deported? If yes, why?
If potential asylum claim: What is your race? Religion? Ethnicity? Political Identity? Do you identify as gay, lesbian, bisexual or transgender?
Have you ever been a witness during a criminal investigation or labor rights violation investigation?
*
Yes
No
Do you suffer from any medical illnesses that may be relevant?
*
J. U VISA SCREENING
Have you ever been a victim of a serious crime in the U.S?
*
Yes
No
If yes, did you report it to the police?
Yes
No
If yes, where and when did you report the crime?:
What crime were you a victim of? Please describe the circumstances of the crime, and the harm (if any) that it caused you:
Did you participate in any investigation of the crime by the police?
Would you be willing to participate in any investigation of the crime?
Yes
No
Was the perpetrator ever referred for investigation, arrested, convicted, or incarcerated for the crime?
Yes
No
Please identify any that apply:
Referred to DA/City Attorney
Arrested
Convicted
Incarcerated
Do you have any names/contact information of any law enforcement officials who worked on the crime? If yes, please list here.
K. T VISA SCREENING
Have you ever been forced to work against your will in the United States?
*
Yes
No
If yes, please describe how you were forced to work against your will. (For example, how were you recruited? What pay and conditions were you promised? What were the actual pay and conditions? Were your documents taken from you? What type of work did you perform – domestic labor? Commercial sex work? How did you get paid?)
Were you ever threatened that you or someone else would be harmed if you didn’t work? If yes, describe what you were told.
How were you able to escape?
Do you know the identity of the traffickers (i.e. those who forced you to work)? If yes, who are they?
Did you report the crime? (If yes, where and when did you report the crime?)
Did you participate in any investigation of the crime? (If yes, how did you help? If no, would you be willing to do so?)
Do you have any names/contact information of any law enforcement officials who worked on the crime? If yes, please list here.
L. DETENTION CONDITIONS/TREATMENT
Are you having any problems at the facility?
*
Have you had any issues involving your personal safety, health, religion, food, or discipline?
*
M. COMMUNITY ADVOCACY
Are you interested in making your case public and using community organizing to stop your deportation?
Yes
No
FOLLOW-UP
Person who did intake:
*
First Name
Last Name
E-mail
*
Phone Number
*
Person who'll do follow-up (if different from intake)
First Name
Last Name
E-mail
Phone Number
Local organization responsible for follow-up:
*
Resources provided?
Describe information provided
Resources provided
Self-help handout
Attorney referral list
Resource List
Pro se resources
Prosecutorial discretion resources
Organizing / advocacy resources
Other
Specific legal referral provided
Technical assistance regarding legal or advocacy next steps provided
Advice given, if any:
Follow-up promised?
Yes
No
No follow-up necessary
If yes, when and type of follow up?
*
Specific follow-up needed / promised?
Provide additional information
*
Yes
No
If yes, specify what information here
Review proceedings, materials
*
Yes
No
Assist in obtaining criminal record report or other information:
*
Yes
No
If yes, specify what information here
Contact ICE or consulate for immediate removal
*
Yes
No
Assist with public advocacy
*
Yes
No
Make legal referral
*
Yes
No
Contact family member
*
Yes
No
Other
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*
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