Client Intake Form

Your Full Name*

First Middle Last

Your Birth Name*

First Middle Last

Other Names Used

If a married beneficiary and you have not yet taken the married surname (last name), please write the name as you would like it to appear on your immigration document:

Note: this will become your legal name.

First Middle Last

Date of Birth*

Home Phone*

Mobile Phone*

Email*

Height*

Weight*

Hair Color*

Eye Color*

Are you Hispanic?*

Race? (Select all applicable boxes)*

White
Asian
Hispanic
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Gender?*

Full Address (Inside the US)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Full Address (Outside of the US)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Place of Birth*

City State / Province / Region Country

Country of Citizenship*

Country

Secondary Country of Citizenship

Country

Married*

Number of Previous Marriages*

Spouse or Partner’s Full Name

First Middle Last

Spouse or Partner's Date of Birth

Spouse or Partner's Place of Birth

City State / Province / Region Country

Date of Marriage

Place of Marriage

City State / Province / Region Country

Children

Child's Name	Date of Birth	Place of Birth (city/state/country)

Please list dates as (MM/DD/YYYY)

Mother’s Full Name

First Middle Last

Mother’s Date of Birth

Mother's Place of Birth

City State / Province / Region Country

Mother’s Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Father’s Full Name

First Middle Last

Father’s Date of Birth

Father’s Place of Birth

City State / Province / Region Country

Father’s Current Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Address History for the past 5 years*

Full Address	Move-in Date	Move-out Date

Please list dates as (MM/DD/YYYY)

Your Employment History for the past 5 years*

Name	Address	Job Title	Start Date	Stop Date

Please list dates as (MM/DD/YYYY)

Have you ever petitioned for another person in an Immigration filing? (such as a Family, Fiance, or Spousal Filing)*

Yes
No

Please Provide Further Information about the other filings:*

Full Name	Date	Purpose for filing	Location of Filing	Outcome of Filing

Have you ever been stopped, arrested, detained, placed in handcuffs, charged, punished, or convicted by law enforcement anywhere in the world?*

Regardless if it was dismissed, sealed, or expunged.

If Yes, and you are the person receiving the immigration benefit, then you MUST request Certified-copies of the Police and Court Records ASAP for EVERY case, and such records must be provided to the Law Firm. This is 100% your responsibility and mandatory in all Immigration Filings.

Yes
No

Further Information is required*

Crime	Date	City	State	Outcome

Would you like to add any comments?

If Yes, and you are the person receiving the immigration benefit, then you MUST request Certified-copies of the Police and Court Records ASAP for EVERY case, and such records must be provided to the Law Firm. This is 100% your responsibility and mandatory in all Immigration Filings.

Have you ever been in Removal or Deportation Proceedings in the US?*

Yes
No

If Yes, and you are the person receiving the immigration benefit, then you must explain and provide as much detail as possible:

Have you ever requested your Credit Report?*

Yes
No

(If you do not have a Social Security Number that you would not have Credit)

Do you have Health Insurance?*

Yes
No

Effective October 15, 2019, Immigration requires a Credit Report when performing a filing to give someone a Green Card. Additionally, Proof of Health Insurance would also be requested for everyone. Such Documents can be provided below:

Drop files here or

Checking your Credit does not lower it. You are able to receive one free credit report from the Credit Agency per year. You can pull your credit report every 4 months, if you alternate Credit agencies. Credit Reports may be ordered online from www.annualcreditreport.com. Our office only needs 1 of the 3 Credit Reports in every Green Card Filing. You may upload it here or provide it later at the request of the Law Firm.

Regarding Health Insurance, you would be required to provide Health Insurance Policy, IRS Form 1095-B or 1095-C, or Military Dependent ID (to prove TRICARE).

Please upload a Passport-style Photo of yourself with a white background, no smiling, hair behind your ears, and no glasses. This photo may be taken with a Phone Camera.

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