Latin American Immigration Association



Personal Information – Petitioner (You)Phone:__________________________________________Name:______________________________________________________________________________________FirstMiddle LastAddress: _____________________________________________________________________________________Date of Birth: ____________________________________Gender: ___________________________________Email Address: _______________________________________________________________________________Marital Status:______________________ Current Immigration Status?____________________________City and State you entered the US:_________________________________________________________Date you entered the US:________________________________________________________________How did you enter the US?________________________________________________________________If Applicable, when did you get your lawful permanent residency? _________________________________Do you have any pending applications with USCIS or Immigration Court? ___________________________If so, what applications? _______________________________________________________________________Personal Information – Beneficiary (Your Relative/Intending Immigrant)Phone:__________________________________________Name:______________________________________________________________________________________FirstMiddle LastAddress: _____________________________________________________________________________________Date of Birth: ____________________________________Gender: ___________________________________Email Address: _______________________________________________________________________________Marital Status:______________________ Current Immigration Status?____________________________City and State you entered the US:_________________________________________________________Date you entered the US:________________________________________________________________How did you enter the US?________________________________________________________________If Applicable, when did you get your lawful permanent residency? _________________________________Do you have any pending applications with USCIS or Immigration Court? ___________________________If so, what applications? _______________________________________________________________________-6350026162000BENEFICIARY ---Complete this section ONLY if applicable:Pending ChargesWhat are the charges? _________________________________________________________________________How many counts? ________________Are all offenses on the same day? ___________________________Criminal RecordDo you have prior arrests in the United States or any other countries? _______________________________If yes, what was the basis of the arrest? __________________________________________________________If yes, where did it happen? ______________________________ When did it happen? __________________Removal ProceedingsHave you ever been placed in deportation or removal proceedings? _________________________________If yes, when and where? _______________________________________________________________________INTENDING IMMIGRANT - Assessment Questions:Have you ever been detained at a Port of Entry or U.S. Border Office? ____________________________If Yes: Where: ____________________________________ When: _________________________________Have you ever been refused entry into the U.S.? _______________________________________________If Yes: Where: ____________________________________ When: _________________________________Have you ever been fingerprinted by an Immigration or Border Patrol Officer? ____________________If Yes: Where: ____________________________________ When: _________________________________Have you ever appeared in front of an Immigration Judge? _____________________________________If Yes: Where: ____________________________________ When: _________________________________Have you ever been temporarily allowed to enter the United States for medical or other reasons without obtaining a visitor visa? ____________________________________________________________If Yes: Where: ____________________________________ When: _________________________________Have you ever been denied any kind of visa? _________________________________________________If Yes: Where: ____________________________________ When: _________________________________Do you have any reason to fear returning to your home country? ________________________________If Yes: Why: ______________________________________________________________________________Have you been involved in gangs, drug cartels or political conflict in the U.S. or your Country? _____If Yes: Where: ____________________________________ When: _________________________________Have you been the victim of a crime while in the U.S.? _________________________________________If Yes: Where: ____________________________________ When: _________________________________Have you ever plead guilty or no contest to any crime in the U.S. or another country? ______________If Yes: Where: ____________________________________ When: _________________________________Have you ever been convicted of a crime involving drugs, weapons or fraud? ____________________If Yes: Where: ____________________________________ When: _________________________________Have you ever been arrested for a crime and no charges were filed or they were dismissed? ________If Yes: What Charges: ____________________________________ When: ___________________________Have you ever accepted public assistance such as “food stamp/EBT” Cash aide or Free Medical Services while in the U.S.? __________________________________________________________________If Yes: What Services : ___________________________________ __________________________________ Where: _______________________________________ When: ____________________________________PETITIONER - Biographical InformationPlace of Birth: ________________________________________Citizenship: ________________________Other Names Used: ___________________________________________________________________________City of Birth: _________________________________________________________________________________Hispanic or Latino_____ Yes_____ NoRace: ______________________________________Height: ___________Weight ____________Hair Color: _______________________________Eye Color: _______________________________Parents:Father’s informationName: ______________________________________________________________________________________FirstMiddleLastPlace of Birth: ___________________________________Date of Birth: ______________________________City and Country of Residence: _________________________________________________________________Mother’s informationName: _______________________________________________________________________________________FirstMiddleLastMaidenPlace of Birth: ___________________________________Date of Birth: ______________________________City and Country of Residence: _________________________________________________________________CURRENT Spouse: _______________________________________Date of Birth: _______________________City and Country of Birth: _____________________________________________________________________Date of Marriage: _________________________Place of Marriage: _________________________________FORMERSpouse: ________________________________________Date of Birth: _______________________City and Country of Birth: _____________________________________________________________________Date of Marriage: _________________________Place of Marriage: _________________________________Date Marriage Ended: _____________________Place Marriage Ended: _____________________________Residence – Last 5 years:_______________________________________________________________ to PRESENT AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate toLast Address outside the United States of more than 1 year:_______________________________________________________________ to ____________AddressDate FromDate toOccupations – Last 5 years______________________________________________________________________ toPRESENTEmployer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate toLast Employer outside the United States of more than 1 year:______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate toDependent and Spouse InformationCURRENT SpouseName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________BENEFICIARY - Biographical InformationPlace of Birth: ________________________________________Citizenship: ________________________Other Names Used: ___________________________________________________________________________City of Birth: _________________________________________________________________________________Hispanic or Latino_____ Yes_____ NoRace: ______________________________________Height: ___________Weight ____________Hair Color: _______________________________Eye Color: _______________________________Parents:Father’s informationName: ______________________________________________________________________________________FirstMiddleLastPlace of Birth: ___________________________________Date of Birth: ______________________________City and Country of Residence: _________________________________________________________________Mother’s informationName: _______________________________________________________________________________________FirstMiddleLastMaidenPlace of Birth: ___________________________________Date of Birth: ______________________________City and Country of Residence: _________________________________________________________________CURRENT Spouse: _______________________________________Date of Birth: _______________________City and Country of Birth: _____________________________________________________________________Date of Marriage: _________________________Place of Marriage: _________________________________FORMERSpouse: ________________________________________Date of Birth: _______________________City and Country of Birth: _____________________________________________________________________Date of Marriage: _________________________Place of Marriage: _________________________________Date Marriage Ended: _____________________Place Marriage Ended: _____________________________Residence – Last 5 years:_______________________________________________________________ to PRESENT AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate to_______________________________________________________________ to ____________AddressDate FromDate toLast Address outside the United States of more than 1 year:_______________________________________________________________ to ____________AddressDate FromDate toOccupations – Last 5 years______________________________________________________________________ toPRESENT Employer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate to______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate toLast Employer outside the United States of more than 1 year:______________________________________________________________________ to _____Employer NameAddressTitleDate FromDate toDependent and Spouse InformationCURRENT SpouseName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ChildName: __________________________________________________Date of Birth: _______________________City & Country of Birth: _______________________________________________________________________Current Address: _____________________________________________________________________________Immigration Status: _______________________________SS#/A# ____________________________________ ................
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