U Visa Intake
Immigrant Victims of Crime Protection Project
Interviewer’s Name:______Date:______
General Information
Name:______
DOB:______Place of Birth:______
A# (if any):______SSN or ITIN (if any):______
Current SAFE Address ______
______
Who lives at this address?:______
Can we write you at this address? □ Yes □ No
Phone (H) ______(W) ______(Other)______
Financial Eligibility for AG Services
Are you currently working? □ Yes □ No Do you have a work permit? □ Yes □ No
What is the current household income? ______
What is the current household size? ______
Does client meet financial eligibility for AG’s services? □ Yes □ No
□ 100% □ 125%(IOLTA) □ < 187½ % (CVCLS) □ 200% (non-IOLTA)
Family/Derivatives Information
Are you married? □Yes □ No □ Unsure:______
If so, name of spouse:______
Immigration status of spouse:______DOB:______
Is spouse the perpetrator? □ Yes □ No
Do you have children? □ Yes □ No
Please include the following information below for each child:
Name / D.O.B. / Place ofResidence
/ ImmigrationStatus / Did child suffer as a result of the crime? Please circle all that apply
Physical Verbal Sexual As Witness
Physical Verbal Sexual As Witness
Physical Verbal Sexual As Witness
Physical Verbal Sexual As Witness
Physical Verbal Sexual As Witness
Physical Verbal Sexual As Witness
Physical Verbal Sexual As Witness
Who is the direct victim of the crime in this case?______
Is the direct victim over 21? □ Yes □ No
List all qualifying derivatives (If over 21: spouse, children. If under 21: spouse, children, parents, unmarried siblings under 18)
Name: ______
Relationship: Date of Birth:
Name: ______
Relationship: Date of Birth:
Name: ______
Relationship: Date of Birth:
Name: ______
Relationship: Date of Birth:
Name: ______
Relationship: Date of Birth:
Name: ______
Relationship: Date of Birth:
***If there are any possible derivatives, complete pages 3 and 4 for each potential derivative.
Name: ______Date of Birth:
Immigration History
1st Entry / 2nd Entry / 3rd Entry / 4th EntryDate of Entry
Place of Entry
Manner of Entry
Status Valid Until
Immigration Contact
Date of
Departure
Reason for Departure
Unlawful Presence
Prior Contact With Immigration
Nature of Immigration Contact: 1st contact 2nd contact 3rd contact 4th contact
Date: ______
Place: ______
Arrested at the border… …………………. Y N Y N Y N Y N
Asked to turn around at the border………. Y N Y N Y N Y N
Detained at the border… ………………… Y N Y N Y N Y N
Fingerprinted ……………………………… Y N Y N Y N Y N
Picture taken… …………………………… Y N Y N Y N Y N
Signed papers… …………………………. Y N Y N Y N Y N
Saw a judge… …………………………… Y N Y N Y N Y N
Granted voluntary departure…………….. Y N Y N Y N Y N
Deported… ………………………………. Y N Y N Y N Y N
*Note: If any prior Immigration contact, you must submit a FOIA and an FBI check
Have you ever:
· Had an Immigration attorney……………………………………………………………… Y N
· Had any type of Immigration status…………………………………………………….. .. Y N
· Applied for any type of Immigration status………………………………………………. Y N
· Had any USC or LPR family members…………………………………………………… Y N
Please explain: ______
______
______
Are you currently in deportation proceedings? ______
______
Name: ______
Public Benefits
Have you ever received benefits from the government? □ Yes □ No If Yes, which ones?
□ WIC □ CHIP □ Food Stamps □ TANF □ Medicaid □ SSI □ Other ______
Criminal History
Have you ever been arrested, either in the United States or elsewhere? □ Yes □ No
If so, for what? ______
______
Place: ______
Date: ______
Were you convicted / found guilty? □ Yes □ No
If so, what was the final disposition? ______
______
Have you received any tickets or citations? □ Yes □ No If so, list:
Date: ______Place: ______Type of Ticket: ______
Date: ______Place: ______Type of Ticket: ______
Date: ______Place: ______Type of Ticket: ______
Date: ______Place: ______Type of Ticket: ______
*Note: client must bring in copy of final disposition for any criminal conviction(s).
Other Potential Grounds of Inadmissibility
Do you have any communicable diseases? yes no ______
Have you had convictions for abuse of drugs or alcohol? yes no ______
Have you signed an I-9 (Form for Employer’s verification of authorization to work), Application for public benefits, or registered to vote, claiming to be a U.S. Citizen?
yes no ______
Have you ever presented/provided false information or false documents to Immigration officials?
yes no ______
U Visa Eligibility Checklist
In the United States, have you been the victim of any of the following crimes or an attempt of any of the following crimes (check all that apply)?
□ Rape □ Abusive sexual contact □ Slave Trade □ Extortion
□ Torture □ Prostitution □ Kidnapping □ Manslaughter
□ Trafficking □ Sexual exploitation □ Abduction □ Murder
□ Incest □ Female genital mutilation □ Obstruction of Justice □ Felonious Assault
□ Domestic Violence □ Being held hostage □ False imprisonment □ Witness tampering
□ Sexual Assault □ Involuntary Servitude □ Blackmail □ Perjury
□ Unlawful Criminal Restraint
□ Any other similar activity in violation of federal, state, or local criminal law______
______
Have you reported the criminal activity to any government agency? □ Yes □ No
--If so, to which agency and to what extent did the agency conduct an investigation regarding your complaint? Please explain:
______
______
______
______
______
______
______
______
Do you know of any law enforcement official, prosecutor, judge, government service, or any government investigator who would be willing to certify that you were/are/are likely to be helpful in the investigation or prosecution of the crime you suffered?
□ Yes □ No
If so, who?
______
______
If you haven’t reported to a government agency about the criminal activity, are you willing to do so?
□ Yes □ No □ N/A
Details of the Criminal Activity (or Activities)
When did the crime(s) occur? ______
Where did the crime(s) occur? ______
______
Who was the perpetrator? ______D.O.B.______
What (if any) is your relationship to the perpetrator? ______
What is the immigration status of the perpetrator? ______
Notes on criminal activity / cooperation with law enforcement:
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
Additional Questions to Consider/Ask:
Did you press charges?
______
If not, did you drop the charges and why?
______
Did the case go to criminal court or was there a prosecution?
______
If so, did you assist with this process?
______
When was the last time you had contact with law enforcement regarding this case?
______
Have you updated law enforcement with your current contact information? (only applicable if the client moved after report was made)
______
Have you met with a therapist or gone to a shelter as a result of this incident? If so who is your therapist? And/or what shelter did you go to?
______
Did you seek medical attention as a result of this incident? If so, where?
______
American Gateways (formerly PAPA)
U Visa Intake, Page 1 of 7