Client Questionnaire

1
Name
First Name
Last Name
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Anguilla
Anguilla
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Bermuda
British Virgin Islands
Canada
Cayman Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guadeloupe
Guatemala
Haiti
Honduras
Jamaica
Martinique
Mexico
Montserrat
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Barthélemy
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Trinidad and Tobago
Turks and Caicos Islands
U.S. Virgin Islands
United States
Country
3
Date of Birth
Date
Year
Month
Day
4
Place of birthWhere were you born?
5
AgeHow old are you?
6
Email
example@example.com
7
Phone Number
Please enter a valid phone number.
8
Do you wish to apply for citizenship?
Yes
No
9
Do you want to apply for U-VISA?
YESNO
10
What type of crime were you a victim of?
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Ok
11
Who was/were the intended victim(s) of the crime?
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Ok
12
Date crime occurred:
Date
Year
Month
Day
13
Do you have the police report?
YESNO
14
Indicate in what way(s) did you cooperate with the police:
Filed criminal charges _Witnessed before a judge
Returned all police calls _Identified suspect _Were interviewed by police
Was interviewed by the police or a detective
Other
15
Was the suspect arrested?
YESNO
16
Was the suspect convicted of the crime?
YESNO
17
Is the criminal case still open or has it been concluded?
Open
Concluded
18
Were there any physical or psychological injuries?
YESNO
19
Which one(s)?
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Ok
20
For what reason do you wish to obtain citizenship?
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Ok
Ok
21
If you are already a green card holder, how did you obtain your permanent residency card?
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Ok
Ok
22
Can you speak, read and write English?
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Ok
Ok
23
For men only: Have you registered for selective service?
YESNO
24
Please provide your registration number
25
Why haven't you applied for the selective services
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Ok
26
Have you had any arrests before or after you obtained residency (including traffic violations)?
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Ok
27
Have you filed your local, state and federal taxes since becoming a resident? If no, explain below:
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Ok
28
Do you owe the IRS or have you failed to pay your local, state or federal taxes? If yes, explain:
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Ok
Ok
29
Do you owe or have you failed to pay child support? If yes, explain:
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Ok
30
Have you left the U.S. for more than 6 months since you received your permanent residency?
YESNO
31
What was the reason and how long were you out of the U.S.?
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Ok
32
Marital Status
Married
Divorced
Separated
Single
Widow
33
Spouse's Name
First Name
Last Name
34
Spouse's Legal Status
Resident
Citizen
Undocumented
Other
35
Spouse's Country of Birth
36
Spouse's Date of Birth
Date
Year
Month
Day
37
Where do you work?
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Ok
38
Do you have any children?
YESNO
39
Name and Legal Status of Your Children
Children's Names
Date of Birth
U.S. Citizen, Legal, Resident, None
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
1
2
3
4
5
6
Children's Names
Row 0, Column 0
Date of Birth
Row 0, Column 1
U.S. Citizen, Legal, Resident, None
Row 0, Column 2
Children's Names
Row 1, Column 0
Date of Birth
Row 1, Column 1
U.S. Citizen, Legal, Resident, None
Row 1, Column 2
Children's Names
Row 2, Column 0
Date of Birth
Row 2, Column 1
U.S. Citizen, Legal, Resident, None
Row 2, Column 2
Children's Names
Row 3, Column 0
Date of Birth
Row 3, Column 1
U.S. Citizen, Legal, Resident, None
Row 3, Column 2
Children's Names
Row 4, Column 0
Date of Birth
Row 4, Column 1
U.S. Citizen, Legal, Resident, None
Row 4, Column 2
Children's Names
Row 5, Column 0
Date of Birth
Row 5, Column 1
U.S. Citizen, Legal, Resident, None
Row 5, Column 2
1 of 6
40
Do you have immediate family who are U.S. Citizens or Legal residents?
Yes
No
41
Who?Do you have immediate family who are U.S. Citizens or Legal residents? Continued.
Sibling(s)
Parent(s)
Spouse
Child(ren)
42
Have you ever applied for residency or for a work permit in the past?
YESNO
43
If "yes" when and how?Have you ever applied for residency or for a work permit in the past? Continued
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Ok
44
Have you ever claimed to be a U.S. Citizen?
YESNO
45
Have you ever presented a fake green card, fake visa or any other fake document?
YESNO
46
If "yes" for what purpose?Have you ever presented a fake green card, fake visa or any other fake document? Continued.
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Ok
Ok
47
Have you obtained a visa to enter the U.S.?
YESNO
48
What age did you enter the U.S.?
49
Have you had a case in Immigration Court?
YESNO
50
When was it?Have you had a case in immigration court? Continued.
Date
Year
Month
Day
51
Have you ever received government assistance?
YESNO
52
What type of assistance?Have you ever received government assistance? Continued.
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Ok
53
Have you ever been a victim of a violent crime?
YESNO
54
Was there a police report made?Have you ever been a victim of a violent crime? Continued
YESNO
55
Did you cooperate with the police?Have you ever been a victim of a violent crime? Continued
YESNO
56
Entries and ExitsIf none press "next"
Entry to USA (Date)
Place of Entry
With or Without Visa
Exit out of US (Date)
1st
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2nd
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3rd
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4th
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
5th
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
6th
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
1st
2nd
3rd
4th
5th
6th
Entry to USA (Date)
Row 0, Column 0
Place of Entry
Row 0, Column 1
With or Without Visa
Row 0, Column 2
Exit out of US (Date)
Row 0, Column 3
Entry to USA (Date)
Row 1, Column 0
Place of Entry
Row 1, Column 1
With or Without Visa
Row 1, Column 2
Exit out of US (Date)
Row 1, Column 3
Entry to USA (Date)
Row 2, Column 0
Place of Entry
Row 2, Column 1
With or Without Visa
Row 2, Column 2
Exit out of US (Date)
Row 2, Column 3
Entry to USA (Date)
Row 3, Column 0
Place of Entry
Row 3, Column 1
With or Without Visa
Row 3, Column 2
Exit out of US (Date)
Row 3, Column 3
Entry to USA (Date)
Row 4, Column 0
Place of Entry
Row 4, Column 1
With or Without Visa
Row 4, Column 2
Exit out of US (Date)
Row 4, Column 3
Entry to USA (Date)
Row 5, Column 0
Place of Entry
Row 5, Column 1
With or Without Visa
Row 5, Column 2
Exit out of US (Date)
Row 5, Column 3
1 of 6
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Have you ever assisted anyone in any way to enter the U.S. Illegally?
Yes
No
58
Who?Have you ever assisted anyone in any way to enter the U.S. Illegally? Continued.
Sibling(s)
Parent(s)
Spouse
Child(ren)
Family
Friend(s)
Other
59
What Year?Have you ever assisted anyone in any way to enter the U.S. Illegally? Continued.
Date
Year
Month
Day
60
Immigration DetentionsIf none press "next"
Detention Date
Location
Voluntary Departure or Deportation
1st
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2nd
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3rd
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4th
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
1st
2nd
3rd
4th
Detention Date
Row 0, Column 0
Location
Row 0, Column 1
Voluntary Departure or Deportation
Row 0, Column 2
Detention Date
Row 1, Column 0
Location
Row 1, Column 1
Voluntary Departure or Deportation
Row 1, Column 2
Detention Date
Row 2, Column 0
Location
Row 2, Column 1
Voluntary Departure or Deportation
Row 2, Column 2
Detention Date
Row 3, Column 0
Location
Row 3, Column 1
Voluntary Departure or Deportation
Row 3, Column 2
1 of 4
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Your Criminal Record ListIf none press "next"
Year of Offense
Type of Offense
Outcome
1st
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2nd
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3rd
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4th
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5th
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
6th
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
1st
2nd
3rd
4th
5th
6th
Year of Offense
Row 0, Column 0
Type of Offense
Row 0, Column 1
Outcome
Row 0, Column 2
Year of Offense
Row 1, Column 0
Type of Offense
Row 1, Column 1
Outcome
Row 1, Column 2
Year of Offense
Row 2, Column 0
Type of Offense
Row 2, Column 1
Outcome
Row 2, Column 2
Year of Offense
Row 3, Column 0
Type of Offense
Row 3, Column 1
Outcome
Row 3, Column 2
Year of Offense
Row 4, Column 0
Type of Offense
Row 4, Column 1
Outcome
Row 4, Column 2
Year of Offense
Row 5, Column 0
Type of Offense
Row 5, Column 1
Outcome
Row 5, Column 2
1 of 6
62
Have you been to our office or have you had a case with us before?
YESNO
63
Please upload any documents related to the immigration case they want to consultEx: Receipt/Approval Notices, police report, etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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64
How did you hear about our office?
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Should be Empty: