CUASVAHH Client Intake Form - English "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Any information you provide on this form is confidential. Answer all questions completely. Please attach your latest tax return form, proof of benefits, or declaration of financial hardship. Your case will not be considered without this. DO NOT attach original documents.Date* MM slash DD slash YYYY Name*Date of Birth* MM slash DD slash YYYY OccupationAddress Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Place of BirthUSCIS #Marital StatusDo you need an interpreter Yes No If Yes, what languageEducation LevelLevel of English capacity (beginner / intermediate / advanced)CURRENT IMMIGRATION STATUS Permanent Resident (Green Card) Refugee Domestic Violence Based / VAWA DACA / TPS US Citizen Undocumented Other How did you get statusOtherAre you in immigration Court? Yes No When and where is your next court date?How many times have you entered the United StatesDates of Entry MM slash DD slash YYYY I-94 #Visa DetailsHISTORY1. Have you ever been arrested or jailed for any offense in the United States or any other country? Yes No 2. Have you been charged with domestic violence or any other violent crimes? Yes No 3. Were you ever a victim of any crime in the United States OR outside the United States? Yes No If yes, please indicate where the crime occurred4. Have you ever been sexually assaulted or a victim of domestic violence in the United States OR outside the United States? Yes No If yes, please indicate where the crime occurred5. Did you report the crime to the police? Yes No If yes when and where?FAMILY INFORMATION SPOUSENameDate of Birth MM slash DD slash YYYY Marriage Date MM slash DD slash YYYY Place of BirthPlace of MarriageStatusUSCIS (A#)CHILDRENNumber of Children0123456NameDate of Birth MM slash DD slash YYYY StatusPlace of BirthUSCIS (A#)NameDate of Birth MM slash DD slash YYYY StatusPlace of BirthUSCIS (A#)NameDate of Birth MM slash DD slash YYYY StatusPlace of BirthUSCIS (A#)NameDate of Birth MM slash DD slash YYYY StatusPlace of BirthUSCIS (A#)NameDate of Birth MM slash DD slash YYYY StatusPlace of BirthUSCIS (A#)NameDate of Birth MM slash DD slash YYYY StatusPlace of BirthUSCIS (A#)Any additional children can be written on the back of this sheet (you must include all your children)WHAT SERVICES ARE YOU LOOKING FOR I want to apply for a family member A family member is applying for me I want to apply for or renew my work permit I want to renew my DACA I want to renew my green card I want to apply for my first green card/adjust my status I want to apply for U.S. citizenship (This is the incorrect intake form) I want to apply for Asylum U-Visa or T-Visa ( I am the victim of a crime or trafficking in the U.S. VAWA ( I am the abused spouse of a citizen or green card holder) Other OtherTO BETTER ASSIST YOU, PLEASE DESCRIBE YOUR CASE IN MORE DETAIL. IF YOU LEAVE THIS SPACE EMPTY YOUR INTAKE WILL BE REJECTED
