Basic Information
Attorney Name
First Name
Last Name
Attorney Email Address
*
Attorney Employer
*
State Public Defender
Contract Attorney
Other
Field Office
Burlington
Cedar Rapids
Council Bluffs
Davenport
Des Moines Adult
Des Moines Juvenile
Dubuque
Iowa City
Marshalltown
Mason City
Nevada
Ottumwa
Sioux City Adult
Sioux City Juvenile
Special Defense Unit
Waterloo Adult
Waterloo Juvenile
Client Date of Birth
/
Month
/
Day
Year
Date
Client Country of Origin
*
Does the client speak English?
Yes
No
What is the client's native language?
Mandarin
Spanish
English
Hindi
Bengali
Portuguese
Russian
Japanese
Western Punjabi
Marathi
Telugu
Wu
Turkish
Korean
French
German
Vietnamese
Tamil
Yue
Urdu (Hindustani)
Javanese
Italian
Egyptian Arabic
Gujarati
Iranian Persian
Bhojpuri
Min Nan
Hakka
Jinyu
Hausa
Kannada
Indonesian (Malay)
Polish
Yoruba
Xiang Chinese
Malayalam
Odia
Maithili
Burmese
Eastern Punjabi
Sunda
Sudanese Arabic
Algerian Arabic
Moroccan Arabic
Ukrainian
Igbo
Northern Uzbek
Sindhi
North Levantine Arabic
Romanian
Tagalog
Dutch
Saʽidi Arabic
Gan
Amharic
Northern Pashto
Magahi
Thai
Saraiki
Khmer
Chhattisgarhi
Somali
Malay (Malaysian Malay)
Cebuano
Nepali
Mesopotamian Arabic
Assamese
Sinhala
Northern Kurdish
Hejazi Arabic
Nigerian Fulfulde
South Azerbaijani
Greek
Chittagonian
Kazakh
Deccan
Hungarian
Kinyarwanda
Zulu
South Levantine Arabic
Tunisian Arabic
Sanaani Spoken Arabic
Min Bei Chinese
Southern Pashto
Rundi
Czech
Taʽizzi-Adeni Arabic
Uyghur
Min Dong Chinese
Sylheti
Select One or More
What is/are the client’s native language(s)?
What is the client's A-number, if known?
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Criminal History
Enter the client's criminal history and add more lines as needed:
Current Criminal Charges
Enter the client's current criminal charges and add more lines as needed:
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Client Immigration Status
What is the client's current immigration status?
*
Lawful Permanent Resident (Green Card)
Refugee
Asylee
Temporary Protected Status
Undocumented
Naturalized Citizen
Deferred Action for Childhood Arrivals (DACA)
Temporary Visa (Tourist, Student, Temporary, Worker)
Unknown Status
Other
When did the client naturalize?
When was the client granted Lawful Permanent Resident (LPR) status?
When did the client enter the U.S. as a refugee?
When was the client granted asylum?
When was the client granted Temporary Protected Status?
When was the client granted DACA status?
What type of temporary visa was granted?
Tourist
Student
Temporary
Worker
Other
When does the client's visa expire?
What is the client's immigration status?
What details are known regarding the client's status?
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U.S. Entry Information
When did the client enter the United States?
*
What was the client's immigration status at entry?
*
How old was the client at entry?
Years
Did the client depart/reenter one or more times?
*
Yes
No
When was the client's most recent entry?
Immigration Applications
Has the client previously applied for immigration benefit?
Yes
No
What did the client apply for?
When did the client apply?
What was the outcome of the application?
Does the client have any current applications?
Yes
No
What is the client applying for?
When did the client apply?
Removals
Has the client ever been removed from the U.S.?
*
Yes
No
When was the client removed?
Where did this occur?
Voluntary Departure(s)
Was the client ever granted voluntary departure?
*
Yes
No
Unsure
When was the client granted voluntary departure?
Where did this occur?
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Immigration Court
Does the client have a current case in immigration court?
*
Yes
No
What details are known about the case?
Has the client ever had a case in immigration court?
*
Yes
No
What details are known about the previous case?
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Immigration Relief Screening
Does the client have any family members who are U.S. Citizens (USCs) or Legal Permanent Resident (LPRs)?
*
Yes
No
Check all that apply:
USC Spouse
USC Parent(s)
USC Sibling(s)
USC Grandparent(s)
USC Children (Under 21)
USC Children (Over 21)
LPR Spouse
LPR Parent(s)
LPR Sibling(s)
LPR Grandparent(s)
LPR Children
Is the client afraid to return to their country of origin?
*
Yes
No
Why is the client afraid to return?
Has the client ever been the victim of a crime in the United States?
*
Yes
No
What was the crime(s)?
Did the client report the crime(s) and provide assistance to law enforcement investigation(s)?
Yes
No
Has the client ever been a victim of domestic violence?
*
Yes
No
Is the perpetrator a USC or LPR?
Yes
No
Is the client under 21 years old and unmarried?
*
Yes
No
Has the client ever been abused, abandoned, or neglected by a parent?
Yes
No
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Submit
What is the client's primary priority or concern?
Would you like to provide any further information? (Client in custody, imminent court date, etc.)
Yes
No
What further information do you want to provide?
Submit
Should be Empty: