Client Intake Form

Client Intake Form (Immigration-Related)

Date:

Petitioner's Information

Full Name:

Date of Birth:

Gender: Male Female

Home/Cell Phone:

Relationship with Beneficiary:

List of Addresses (Last 5 Years)

If you have additional information, provide it in the spaces below

Address 1:

City: State: ZIP:

Date From: Date To:

Address 2:

City: State: ZIP:

Date From: Date To:

Marital Information

If you have additional information, provide it in the spaces below

Current Marital Status:
Single Never Married Married Divorced Widowed Separated Annulled

Current Spouse:

Marriage Date From: To:

Prior Spouse:

Marriage Date From: To:

Parents' Information

Parent 1’s Name:

Date of Birth:

Gender: Male Female

Place of Birth:

Residing Address:

Parent 2's Information

Parent 2's Name:

Date of Birth (DOB):

Gender: Male Female

Place of Birth:

Residing Address:

Immigration Status

Immigration Status: US Citizen Lawful Permanent Resident

Citizenship acquired through: Birth in USA Naturalization Parents

Certificate/Class Number:

Issuance/Admission Date:

Place of Issuance/Admission:

Did you obtain lawful permanent status via marriage to a U.S. citizen or permanent resident? Yes No

Employment History (Last 5 Years)

If you have additional information, provide it in the spaces below

Employer 1:

Employer 1 Address:

Occupation:

Date From: Date To:

Employer 2:

Employer 2 Address:

Occupation:

Date From: Date To:

Biographic Information

Ethnicity/Race: Hispanic/Latino Caucasian Asian Native American African American Other

Height (Feet & Inches):

Weight (lbs):

Eye Color:

Hair Color:

Beneficiary's Information

Full Name:

Date of Birth (DOB):

Gender: Male Female

Place of Birth:

A# / SS#:

USCIS Online#:

Cell Phone:

Email:

List of Addresses (Last 5 Years)

Address 1:

City: State: ZIP:

Date From: Date To:

Address 2:

City: State: ZIP:

Date From: Date To:

US Address (where you intend to live):

List of Marital Information

Current Marital Status:
Single Never Married Married Divorced Widowed Separated Annulled

Current Spouse:

Marriage Date From: To:

Prior Spouse:

Marriage Date From: To:

Children Information

1st Child's Name:

1st Child's Date of Birth (DOB):

1st Child's Place of Birth:

Children Information

2nd Child's Name:

2nd Child's Date of Birth (DOB):

2nd Child's Place of Birth:

Parents' Information

Parent 1's Name:

Parent 1's Date of Birth (DOB):

Parent 1's Gender: Male Female

Parent 1's Place of Birth:

Parent 1's Residing Address:

Parent 2's Name:

Parent 2's Date of Birth (DOB):

Parent 2's Gender: Male Female

Parent 2's Place of Birth:

Parent 2's Residing Address:

Employment History (Last 5 Years)

Employer 1:

Employer 1 Address:

Occupation:

Date From: Date To:

Employer 2:

Employer 2 Address:

Occupation:

Date From: Date To:

Application Type

Application Type: Family Employment Refugee Special Immigrant Crime Victim Other

Additional Questions

Has anyone ever filed a petition for you? Yes No

Have you ever been in the United States? Yes No

Have you been in immigration proceedings? Yes No

Were you the one who read and filled this form? Yes No

Did you have a preparer for this form? Yes No

Additional Information

Additional Information, if any: Petitioner Beneficiary

List of Addresses (Last 5 Years)

Address 3:

City: State: ZIP:

Date From: Date To:

Address 4:

City: State: ZIP:

Date From: Date To:

List of Marital Information

Prior Spouse:

Marriage Date From: To:

Parents' Information

Parent 3's Name:

Parent 3's Date of Birth (DOB):

Parent 3's Gender: Male Female

Parent 3's Place of Birth:

Parent 3's Residing Address:

Parent 4's Name:

Parent 4's Date of Birth (DOB):

Parent 4's Gender: Male Female

Parent 4's Place of Birth:

Parent 4's Residing Address:

Employment History (Last 5 Years)

Employer 3:

Employer 3 Address:

Occupation:

Date From: Date To:

Employer 4:

Employer 4 Address:

Occupation:

Date From: Date To:

Additional Information

Additional Information for: Petitioner Beneficiary

List of Addresses (Last 5 Years)

Address 3:

City: State: ZIP:

Date From: Date To:

Address 4:

City: State: ZIP:

Date From: Date To:

List of Marital Information

Prior Spouse:

Marriage Date From: To:

Parents and Children's Information

Parent 3's Name:

Parent 3's Date of Birth (DOB):

Parent 3's Gender: Male Female

Parent 3's Place of Birth:

Parent 3's Residing Address:

3rd Child's Name:

3rd Child's Date of Birth (DOB):

3rd Child's Place of Birth:

4th Child's Name:

4th Child's Date of Birth (DOB):

4th Child's Place of Birth:

Employment History (Last 5 Years)

Employer 3:

Employer 3 Address:

Occupation:

Date From: Date To:

Employer 4:

Employer 4 Address:

Occupation:

Date From: Date To: