CUASVAHH VICTIMS OF CRIME FORM - ENGLISH Any information you provide on this form is confidential. "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Date MM slash DD slash YYYY NameDate of Birth MM slash DD slash YYYY OccupationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email* Is it safe to contact you by mail at this address? Yes No Is it safe to contact you by text at this phone number? Yes No Place of BirthUSCIS #Marital StatusDo you need an interpreter Yes No What languageEducation LevelLevel of English capacity (beginner / intermediate / advanced)CURRENT IMMIGRATION STATUSQUESTIONS Did youEnter the U.S. with a visa (i.e., tourist visa, student visa, family, etc.) Yes No Enter without inspection and/or documentation? Yes No Are you in immigration court? Yes No When and where is your next immigration court date? MM slash DD slash YYYY How many times have you entered the US?Dates of entry MM slash DD slash YYYY Visa details if applicableFAMILY INFORMATION . SPOUSENameDate of Birth MM slash DD slash YYYY Marriage Date MM slash DD slash YYYY Place of BirthPlace of MarriageStatusUSCIS (A#)CHILDRENNumber of children012345NameDate 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#) QUESTIONS Have you ever been represented by an attorney or someone else assisting you with immigration or other legal issues? Yes No Who?Type of caseWhen did you last have contact with this personDOMESTIC VIOLENCEHave you, your spouse, or another relative ever submitted any type of immigration petition for you? Yes No When?Type of PetitionHave you ever been physically assaulted or sexually assaulted by any person? Yes No What is your relationship to the abuser? Legal Spouse Cohabitating Dating relationship (not cohabitating) Roommate Stranger Other Please explainThis field is hidden when viewing the formHAS ANYONE EVER Prevented you from using the phone? Prevented you from talking to family or friends? Followed you or monitored everything you did? Destroyed your property? Threatened to harm you? Threatened to harm your children? Threatened to harm your property? Threatened to harm your pets? Called you names? Humiliated you? Constantly criticized you or your family? Exhibited extreme jealousy? Accused you of being unfaithful? Controlled all the money? Prevented you from having access to money? Prevented you from getting a job? Forced you to work? Forced you to do something illegal or that you did not want to do? Threatened to take away your children? Threatened to have you deported? Hidden or kept you from accessing your passport or other important identity documents? HAS ANYONE EVER Prevented you from using the phone? Prevented you from talking to family or friends? Followed you or monitored everything you did? Destroyed your property? Threatened to harm you? Threatened to harm your children? Threatened to harm your property? Threatened to harm your pets? Called you names? Humiliated you? Constantly criticized you or your family? Exhibited extreme jealousy? Accused you of being unfaithful? Controlled all the money? Prevented you from having access to money? Prevented you from getting a job? Forced you to work? Forced you to do something illegal or that you did not want to do? Threatened to take away your children? Threatened to have you deported? Hidden or kept you from accessing your passport or other important identity documents? TRAFFICKING SCREENER This field is hidden when viewing the formHAS ANYONE EVER Forced you to work for them? Make you work or do something you did not want to do once in the United States in exchange for helping you enter? Threaten your family back home if you did not do what they asked? Promise you a job in the United States? Make you work at a job without getting the payment you thought you would get? Make you work in a place where you felt afraid and/or unsafe? Pressure you to carry an item with you across the border? Forced you to have sex with them in exchange for money? Forced you to have sex with them in exchange for housing, food, or to pay off a debt? HAS ANYONE EVER Forced you to work for them? Make you work or do something you did not want to do once in the United States in exchange for helping you enter? Threaten your family back home if you did not do what they asked? Promise you a job in the United States? Make you work at a job without getting the payment you thought you would get? Make you work in a place where you felt afraid and/or unsafe? Pressure you to carry an item with you across the border? Forced you to have sex with them in exchange for money? Forced you to have sex with them in exchange for housing, food, or to pay off a debt? LAW ENFORCEMENT SCREENERLAW ENFORCEMENT SCREENERHave you ever called 911 and reported any of the things listed, or otherwise talked with law enforcement or prosecutors in the United States? Yes No What items marked above were reported, investigated or charged?Date crime reportedWho reported the crime?Was the person doing the things marked above Arrested? Charged with a crime? Convicted? Who was the crime reported to?Law Enforcement AgencyCounty Attorney/Prosecutor’s Office
