<p> 1</p><p>GROSSMAN LAW, LLC IMMIGRATION INTAKE QUESTIONNAIRE </p><p>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. </p><p>BRIEFLY EXPLAIN THE MAIN REASONS YOU ARE SEEKING IMMIGRATION ADVICE______</p><p>PERSONAL INFORMATION </p><p>1. First & Middle Names ______</p><p>Last Name______Any Other Names Used (including Maiden Name) ______</p><p>2. Home Address: Number & Street ______Apt No, City, Province, Postal Code ______Country______</p><p>Can correspondence be sent to the above address? Yes___No___. If no, where should correspondence be sent? ______</p><p>3. Date of Birth (MO/DAY/YR)______</p><p>4. Country of Birth______</p><p>5. Social Security Number ______</p><p>6. Telephone Numbers: Home ______Work______</p><p>Fax ______Cell______</p><p>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</p><p>Can we contact you at any of the telephone numbers listed above? Yes___No____</p><p>If no, which number(s) can you be contacted at? ______</p><p>7. E-Mail ______</p><p>8. City and Country of Last Residence ______</p><p>IMMIGRATION HISTORY </p><p>9. Alien Registration Number A______</p><p>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.)</p><p>11. Last Entry Into U.S.: When ______Where ______Reason______Visa Status ______Until: ______</p><p>I-94 Number (If applicable) ______</p><p>List All Prior Entries (When, Where, Reason, Visa Status)? A) ______B) ______C) ______</p><p>EMPLOYMENT INFORMATION</p><p>12. Employer’s Name______Employer’s Address: Number & Street ______Suite No._____</p><p>City, Province, Postal Code, Country ______</p><p>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. 3</p><p>13. Name of Work Supervisor and/or Contact______</p><p>Phone Number Of Supervisor/Contact ______</p><p>Fax Number Of Supervisor/Contact </p><p>Can we contact your employer at any of the telephone numbers listed above? Yes___No____</p><p>INFORMATION ON YOUR MARITAL STATUS (WRITE “N/A” IF NOT APPLICABLE)</p><p>14. Marital Status: __ Single __Married __Separated __Divorced __Widowed __Never Married</p><p>A) Name of Spouse ______</p><p>B) Immigrant Status in U.S.______B) Address of Spouse (if living apart): ______C) Birth Date of Spouse______D) Social Security Number ______</p><p>E) Alien Registration Number: A______F) Date of Marriage______</p><p>G) Place of Marriage______</p><p>H) City, Province, and Country of Birth of Spouse______I) Spouse’s Passport (Countries)______</p><p>Passport Number ______Date Issued ______Expiration Date______</p><p>J) If Most Recent Marriage was Terminated by Divorce or Death Date ______Where ______</p><p>FAMILY</p><p>15. Children: If applicable, please provide the following information for all children including step children and adopted children</p><p>Child 1: </p><p>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. 4</p><p>A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______</p><p>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______</p><p>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______</p><p>16. Parents: Please provide the following information for your parents: </p><p>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?______</p><p>Father: A) Full Name______B) Date of Birth______C) Place of Birth______D) Place of Residence______</p><p>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. 5</p><p>E) Immigrant status in U.S.______F) Country of Citizenship______G) Deceased?______</p><p>17. Siblings: If applicable, please provide the following information for all siblings.</p><p>Sibling 1: </p><p>A) Full Name______B) Male___ Female___ C) Marital Status ______D) Date of Birth______E) Place of Birth______F) Place of Residence______G) Immigrant Status______</p><p>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______</p><p>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______</p><p>18. Do Either You or Your Spouse Have a Grandparent Who Was Born in the U.S. or Became a Naturalized Citizen? Yes___ No___</p><p>19. Has An Immigrant (Green Card or I-130) Petition Ever Been Filed for: </p><p>A) You? Yes___ No___ If Yes, Please State When, Where, What Type, and the Status of that Application______</p><p>B) Your Spouse? Yes___ No___</p><p>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. 6</p><p>If Yes, Please State When, Where, What Type, and the Status of that Application______</p><p>C) Children? Yes___ No___ If Yes, Please State When, Where, What Type, and the Status of that Application______</p><p>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. ______</p><p>21. Have You or Your Spouse Ever Worked for the United States Government, Including the Military? Yes___ No___</p><p>EDUCATION AND EXPERIENCE</p><p>NOTE: In lieu of completing this section, please provide us with an updated curriculum vitae.</p><p>23. EDUCATION</p><p>Names of Schools, Field Of Degrees or Certificates Colleges or Universities Study Received ______</p><p>PERSONAL BACKGROUND (PLEASE ANSWER ALL QUESTIONS) </p><p>24. Have You Ever:</p><p>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. ______</p><p>B) Been Treated for A Mental Disorder, Mental Retardation, Drug Addiction, or Alcoholism? Yes___ No___</p><p>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. 7</p><p>If Yes, Please Provide Additional Information. ______</p><p>C) Been Given a Citation? Yes___ No___ If Yes, Please Provide Additional Information. ______</p><p>D) Been Given a Ticket? Yes___ No___ If Yes, Please Provide Additional Information. ______</p><p>E) Been Given Probation? Yes___ No___ If Yes, Please Provide Additional Information. ______</p><p>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. ______</p><p>G) Worked Without Authorization? Yes___ No___ If Yes, Please Provide Additional Information. ______</p><p>H) Overstayed Any U.S. Visa, or Otherwise Violated Your Visa Status? If Yes, Please Provide Additional Information. ______</p><p>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______</p><p>I) Been Involved with Drugs or Narcotics Anywhere in the World? Yes___ No___</p><p>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. 8</p><p>If Yes, Please Provide Additional Information. ______</p><p>J) Been a Victim of Domestic Violence? Yes___ No___ If Yes, Please Provide Additional Information. ______</p><p>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. ______</p><p>25. Have You Ever Been Required to Appear in Court? Yes___No___. If Yes, When, Where, and What Was the Final Result?</p><p>______</p><p>26. Have You Ever Been Required to Appear in a Criminal Proceeding? If Yes, When, Where, and What Was the Final Result?</p><p>______(Please provide copies of all documents regarding all prior contact with the Courts.)</p><p>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?</p><p>______</p><p>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.)</p><p>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. 9</p><p>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: ______</p><p>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? ______</p><p>31. Have you and your Family Filed all Your U.S. Income Taxes? Yes___ No___</p><p>Please sign and date this Questionnaire to confirm that the contents are true and correct to the best of your knowledge and belief</p><p>______Signature Date</p><p>How did you hear of us?</p><p>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______</p><p>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. </p>