Grossman Law, Llc

GROSSMAN LAW, LLC IMMIGRATION INTAKE QUESTIONNAIRE

Instructions: Please fill out the questionnaire, providing as much information as possible and writing “N/A” or “None” where applicable. The answers you provide are confidential and can never be provided to anyone outside of our firm without your permission.

BRIEFLY EXPLAIN THE MAIN REASONS YOU ARE SEEKING IMMIGRATION ADVICE______

PERSONAL INFORMATION

1. First & Middle Names ______

Last Name______Any Other Names Used (including Maiden Name) ______

2. Home Address: Number & Street ______Apt No, City, Province, Postal Code ______Country______

Can correspondence be sent to the above address? Yes___No___. If no, where should correspondence be sent? ______

3. Date of Birth (MO/DAY/YR)______

4. Country of Birth______

5. Social Security Number ______

6. Telephone Numbers: Home ______Work______

Fax ______Cell______

Please return your completed questionnaire to Grossman Law, LLC, Attn: Sandra Grossman, 110 N. Washington St. Suite 350, Rockville, MD 20850. You may also email a copy of the questionnaire to Sandra Grossman at [email protected] or via fax at (240) 453-0915. 2

Can we contact you at any of the telephone numbers listed above? Yes___No____

If no, which number(s) can you be contacted at? ______

7. E-Mail ______

8. City and Country of Last Residence ______

IMMIGRATION HISTORY

9. Alien Registration Number A______

10. List all your Passports (Countries), Passport Numbers, Date Issued, and Expiration Date A) ______B) ______C) ______(You may be asked to provide our office with copies of all passports.)

11. Last Entry Into U.S.: When ______Where ______Reason______Visa Status ______Until: ______

I-94 Number (If applicable) ______

List All Prior Entries (When, Where, Reason, Visa Status)? A) ______B) ______C) ______

EMPLOYMENT INFORMATION

12. Employer’s Name______Employer’s Address: Number & Street ______Suite No._____

City, Province, Postal Code, Country ______

13. Name of Work Supervisor and/or Contact______

Phone Number Of Supervisor/Contact ______

Fax Number Of Supervisor/Contact

Can we contact your employer at any of the telephone numbers listed above? Yes___No____

INFORMATION ON YOUR MARITAL STATUS (WRITE “N/A” IF NOT APPLICABLE)

14. Marital Status: __ Single __Married __Separated __Divorced __Widowed __Never Married

A) Name of Spouse ______

B) Immigrant Status in U.S.______B) Address of Spouse (if living apart): ______C) Birth Date of Spouse______D) Social Security Number ______

E) Alien Registration Number: A______F) Date of Marriage______

G) Place of Marriage______

H) City, Province, and Country of Birth of Spouse______I) Spouse’s Passport (Countries)______

Passport Number ______Date Issued ______Expiration Date______

J) If Most Recent Marriage was Terminated by Divorce or Death Date ______Where ______

FAMILY

15. Children: If applicable, please provide the following information for all children including step children and adopted children

Child 1:

A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______

Child 2: A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______

Child 3: A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______

16. Parents: Please provide the following information for your parents:

Mother: A) Full Name______B) Date of Birth______C) Place of Birth______D) Place of Residence______E) Immigrant status in U.S.______F) Country of Citizenship______G) Deceased?______

Father: A) Full Name______B) Date of Birth______C) Place of Birth______D) Place of Residence______

E) Immigrant status in U.S.______F) Country of Citizenship______G) Deceased?______

17. Siblings: If applicable, please provide the following information for all siblings.

Sibling 1:

A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______

Sibling 2: A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______

Siblings 3: A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______

18. Do Either You or Your Spouse Have a Grandparent Who Was Born in the U.S. or Became a Naturalized Citizen? Yes___ No___

19. Has An Immigrant (Green Card or I-130) Petition Ever Been Filed for:

A) You? Yes___ No___ If Yes, Please State When, Where, What Type, and the Status of that Application______

B) Your Spouse? Yes___ No___

If Yes, Please State When, Where, What Type, and the Status of that Application______

C) Children? Yes___ No___ If Yes, Please State When, Where, What Type, and the Status of that Application______

20. Has a Labor Certification Ever Been Filed for You, Your Spouse, or Children? Yes___ No___ If Yes, Please State When, Where, What Type, And the Status of that Application. ______

21. Have You or Your Spouse Ever Worked for the United States Government, Including the Military? Yes___ No___

EDUCATION AND EXPERIENCE

NOTE: In lieu of completing this section, please provide us with an updated curriculum vitae.

23. EDUCATION

Names of Schools, Field Of Degrees or Certificates Colleges or Universities Study Received ______

PERSONAL BACKGROUND (PLEASE ANSWER ALL QUESTIONS)

24. Have You Ever:

A) Made an Incorrect or Fraudulent Statement or Misrepresented a Fact to Obtain or Try to Obtain Any Visa or Immigration Benefit from the U.S., Including Entry Into the U.S.? Yes___ No___ If Yes, Please Provide Additional Information. ______

B) Been Treated for A Mental Disorder, Mental Retardation, Drug Addiction, or Alcoholism? Yes___ No___

If Yes, Please Provide Additional Information. ______

C) Been Given a Citation? Yes___ No___ If Yes, Please Provide Additional Information. ______

D) Been Given a Ticket? Yes___ No___ If Yes, Please Provide Additional Information. ______

E) Been Given Probation? Yes___ No___ If Yes, Please Provide Additional Information. ______

F) Been Convicted or Confined In a Jail or Prison? Yes___ No___ If so, Was It for Political Reasons? Yes___ No___ If Yes, Please Provide Additional Information. ______

G) Worked Without Authorization? Yes___ No___ If Yes, Please Provide Additional Information. ______

H) Overstayed Any U.S. Visa, or Otherwise Violated Your Visa Status? If Yes, Please Provide Additional Information. ______

H) Been Convicted of Any Crime Either in the U.S. or Anywhere in the World? Yes___ No___ If Yes, Please Note Previous Convictions and Include Date and Place of Final Dispositions if Available______

I) Been Involved with Drugs or Narcotics Anywhere in the World? Yes___ No___

If Yes, Please Provide Additional Information. ______

J) Been a Victim of Domestic Violence? Yes___ No___ If Yes, Please Provide Additional Information. ______

K) Been the Victim of a Crime in the U.S. or Assisted in the Investigation or Prosecution of a Crime against you or Another Person? Yes___ No___ If Yes, Please Provide Additional Information. ______

25. Have You Ever Been Required to Appear in Court? Yes___No___. If Yes, When, Where, and What Was the Final Result?

______

26. Have You Ever Been Required to Appear in a Criminal Proceeding? If Yes, When, Where, and What Was the Final Result?

______(Please provide copies of all documents regarding all prior contact with the Courts.)

27. Have You Ever Been Required to Appear in U.S. Immigration Court or Been the Subject of U.S. Removal, Deportation or Exclusion Proceedings? Yes___ No___ If Yes, When, Where, and What Was the Final Result?

______

28. Have You, Your Spouse, or Children Been Questioned or Arrested by the Immigration Service? Yes___ No___ If Yes, When, Where, and What Was the Final Result? ______(Please provide copies of all documents regarding all prior contact with the immigration Service.)

29. Do You or Your Spouse Fear Harm in Your Home Country or are You Afraid That Certain Groups or Persons in Your Home Country Might Try to Hurt You? Yes___ No___ If Yes, Please Explain: ______

30. Have You or Your Spouse ever been in the US on a J-1 Visa? Yes___ No___ If Yes, Then on Which Program, and were either of you Subject to the Requirement That You Return to Your Home Country for Two Years? ______

31. Have you and your Family Filed all Your U.S. Income Taxes? Yes___ No___

Please sign and date this Questionnaire to confirm that the contents are true and correct to the best of your knowledge and belief

______Signature Date

How did you hear of us?

1. Internet Search  2. Search through the American Immigration Lawyers Association (AILA)  3. Referral from another attorney  a. Name of attorney______4. Referral from previous Grossman Law, LLC client  a. Name of client______5. Other. Please specify______

Please return your completed questionnaire to Grossman Law, LLC, Attn: Sandra Grossman, 110 N. Washington St. Suite 350, Rockville, MD 20850. You may also email a copy of the questionnaire to Sandra Grossman at [email protected] or via fax at (240) 453-0915.