Date Intake Attorney Name/Contact Info

Date Intake Attorney Name/Contact Info

Date _______________
Intake Attorney Name/Contact Info __________________________________________
____________________________________________________________________________________________
Name ____________________________________
Facility ID __________ A# ____-______-______ Sex: M F
Age/DOB _____________________ Citizenship ___________________ English? Y/N Other ________________
Date/manner/place of entry __________________________________________
Current status: □ EWI/PWI
□ LPR (admission: _________) □ Asylee/Refugee □ TPS □ NIV/BCC (status/exp ____________)
Absences from U.S. (date and length of departure) ___________________________________________________
____________________________________________________________________________________________
NTA issued/served date_________________ □ 212(a)(6)(A)(i) [PWI] □ 212(a)(2)(A)(i) [CIMT] [□ petty offense?]
□ 212(a)(2)(A)(i)(II) [drugs] □ 237(a)(1)(B) [present in violation/visa overstay] □ 237(a)(1)(C) [status violator]
□ 237(a)(2)(A)(i) [CIMT] □ 237(a)(2)(A)(ii) [CIMTs] □ 237(a)(2)(A)(iii) [AF] □ 237(a)(2)(B) [drugs]
□ 237(a)(2)(E)(i) [DV] □ other __________________________________________________________________
Criminal History: □ NONE □ yes: list charge, date of offense/conviction, actual plea/sentence imposed/suspended/served)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Judge: _______________ Bond: DHS or IJ? □ $_________ □ No bond □ Mandatory □ M/Redetermine/Joseph
Pleadings/Challenge NTA/Grounds?_______________________________________________________________
Next court date _______________ Not before EOIR: □ outstanding/absentia □ reinstatement □ admin removal
Family members in U.S/Immigration status □ mom _____________________ □ dad __________________
□ spouse _____________________ □ children ____________________________________________________
□ siblings/other ______________________________________________________________________________
Immigrant petition: Priority date __________ Pending/Approved/Denied/Revoked? □ CSPA □ § 245(i) eligible?
□ Petitioner name/relationship ___________________________________________________________________
Relief: □ Derivative USC □ Registry (entry <1/1/72 and GMC) □ AOS: Family/Asylee/Employment/Readjusting
□ Self-petition: VAWA/SIJS
Waiver: □ 209(c) [refugee/asylee] □ 212(h) [criminal] □ 212(i) [fraud] □ 212(k)
[ineligible at entry] □ 237(a)(1)(H) [fraud] Qualifying relatives: __________________________________________
Cancellation: □ LPR (7/5 LPR) □ non-LPR (10 w/GMC, hardship) □ VAWA (3 yrs w/GMC, hardship) □ 212(c)
VD □ pre-hearing (no GMC requirement) □ at conclusion (≥1 year before NTA served, 5 years GMC)
□ Asylum/Withholding: race/religion/nationality/social group/political ____________________________________
□ One-Year issue/exception?____________________________________________ □ CAT □ TPS ___________
□ NACARA (Nicaragua/Cuba: entry < 12/1/95 & asylum < 4/1/00; El Salvador: entry < 9/19/90 & ABC/TPS
<10/31/91; Guatemala: entry < 10/1/90 & ABC < 12/31/91; El Salvador/Guatemala: asylum < 4/1/90;
children/spouses of El Salvador/Guatemala: entry <10/1/90) □ T/U Visa? LEA and trafficking/crime details
____________________________________________________________________________________________
□ Mental health issues _________________________________________________________________________
ADVISAL REGARDING INTAKE/LEGAL REPRESENTATION
I understand that the intake attorney or representative is not my attorney or representative in my immigration court removal
proceedings. In addition, I have willingly given the information above, and authorize its disclosure to other parties for the
purpose of obtaining pro bono/volunteer legal assistance.
________________________________________
Signature
______________
Date
Yo entiendo que el abogado o el representante no es mi abogado ni mi represantante en mi caso de deportacion enfrente del
Tribunal de Inmigracion. Ademas, yo afirmo que yo di de buena voluntad la informacion en esta hoja y yo autorizo que esta
informacion pueda ser utilizada por otros personas con el proposito de obtener asistencia legal de abogados voluntarios.
____________________________
Firma
_______________
Fecha