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GROSSMAN LAW, LLC
ASYLUM QUESTIONNAIRE

Instructions: Please complete the questionnaire, providing as much information as possible and writing“N/A” or “None” where applicable.Please answer every questions – leaving none blank. The answers you provide are confidential and can never be provided to anyone outside of our firm without your permission. Please answer each question completely as this questionnaire will be used to complete your I-589 Application for Asylum which requires extremely detailed biographical information.

PERSONAL INFORMATION

  1. First & Middle Names ______

LastName______

Any Other Names Used (including Maiden Name) ______

  1. Provide the following Information about your residences during the past 5 years. List your present address first:

Present Address:

A)Number and street______

B)City/Town______

C)Department/Province/State______

D)Country______

E)Dates: From (Mo/Yr)______To (Mo/Yr)______

Previous Address:

A)Number and street______

B)City/Town______

C)Department/Province/State______

D)Country______

E)Dates: From (Mo/Yr)______To (Mo/Yr)______

Previous Address:

A)Number and street______

B)City/Town______

C)Department/Province/State______

D)Country______

E)Dates: From (Mo/Yr)______To (Mo/Yr)______

Previous Address:

A)Number and street______

B)City/Town______

C)Department/Province/State______

D)Country______

E)Dates: From (Mo/Yr)______To (Mo/Yr)______

Previous Address:

A)Number and street______

B)City/Town______

C)Department/Province/State______

D)Country______

E)Dates: From (Mo/Yr)______To (Mo/Yr)______

  1. List your last address where you lived before coming to the United States. If this is not the country where you fear persecution, also list the last address in the country where you fear persecution:

A)Number and street______

B)City/Town______

C)Department/Province/State______

D)Country______

E)Dates: From (Mo/Yr)______To (Mo/Yr)______

  1. Date of Birth (MO/DAY/YR)______
  1. Country of Birth______
  1. Social Security Number ______
  1. Telephone Numbers: Home ______

Work______

Fax ______

Cell______

Can we contact you at any of the telephone numbers listed above? Yes___No____

If no, which number(s) can you be contacted at?

______

  1. E-Mail ______
  1. City and Country of Last Residence ______
  1. Are you fluent in English?Yes___No____
  1. What other languages do you speak fluently? ______

IMMIGRATION HISTORY

  1. Alien Registration Number A (If any)______
  1. List all your Passports (Countries), Passport Numbers, Date Issued, and Expiration Date

A)______

B)______

C)______

(You may be asked to provide our office with copies of all passports.)

  1. Last Entry Into U.S.: When ______

Where ______

Reason______

Visa Status ______Until: ______

I-94 Number (If applicable) ______

List All Prior Entries (When, Where, Reason, Visa Status)? *For asylum applicants, as necessary please attach an addendum listing each entry into the U.S. beginning with your most recent entry. List date (mm/dd/yyyy), place, and your status for each entry. Begin with your most recent entry.

A)______

B) ______

C)______

D)______

E)______

F)______

G)______

H)______

I)______

J)______

K)______

EMPLOYMENT INFORMATION

  1. Please provide the following information about your employment during the last five years. List your present employment first.

Present employment

A)Name and address of Employer______

______

B)Your Occupation: ______

C)Dates of Employment (month and year began employment and ended employment): ______

Previous employment

A)Name and address of Employer______

______

B)Your Occupation: ______

C)Dates of Employment (month and year began employment and ended employment): ______

Previous employment

A)Name and address of Employer______

______

B)Your Occupation: ______

C)Dates of Employment (month and year began employment and ended employment): ______

Previous employment

A)Name and address of Employer______

______

B)Your Occupation: ______

C)Dates of Employment (month and year began employment and ended employment): ______

INFORMATION ON YOUR MARITAL STATUS(WRITE “N/A” IF NOT APPLICABLE)

  1. Marital Status:

__ Single __Married __Separated __Divorced __Widowed __Never Married

A)Alien Registration number (if any):______

B)Passport/ID Card No. (if any):______

C)U.S. Social security number if any:______

D)Complete last name: ______

E)Middle Name: ______

F)First Name: ______

G)Male___ Female___

H)Date of Birth______

I)City and county of birth:______

J)Nationality/Citizenship: ______

K)Race, ethnic or tribal group: ______

L)Is Spouse in the U.S.?______

M)If not in U.S., please specify location:______

N)Place of last entry to U.S.:______

O)Date of last entry to U.S. (mm.dd.yyyy): ______

P)I-94 No. (if any): ______

Q)Status when last admitted (visa type): ______

R)What is your Spouse’s current status:______

S)What is the expiration date of his/her current authorized stay?______

T)If in the U.S., is your spouse to be included in your asylum application?

  1. Yes____
  2. No_____

J) If Most Recent Marriage was Terminated by Divorce or Death

Date ______Where ______

FAMILY

  1. Children: If applicable, please provide the following information for all childrenincluding step children and adopted children. Please attach addendum as necessary.

Child 1:

A)Alien Registration number (if any):______

B)Passport/ID Card No. (if any):______

C)Marital Status (married/divorced/separated/single)______

D)U.S. Social security number if any:______

E)Complete last name: ______

F)Middle Name: ______

G)First Name: ______

H)Male___ Female___

I)Date of Birth______

J)City and county of birth:______

K)Nationality/Citizenship: ______

L)Race, ethnic or tribal group: ______

M)Is this child in the U.S.?______

N)If not in U.S., please specify location:______

O)Place of last entry to U.S.:______

P)Date of last entry to U.S. (mm.dd.yyyy): ______

Q)I-94 No. (if any): ______

R)Status when last admitted (visa type): ______

S)What is your child’s current status: ______

T)What is the expiration date of his/her current authorized stay?______

U)If in the U.S., is your child to be included in your asylum application?

  1. Yes____
  2. No_____

Child 2:

A)Alien Registration number (if any):______

B)Passport/ID Card No. (if any):______

C)Marital Status (married/divorced/separated/single)______

D)U.S. Social security number if any:______

E)Complete last name: ______

F)Middle Name: ______

G)First Name: ______

H)Male___ Female___

I)Date of Birth______

J)City and county of birth:______

K)Nationality/Citizenship: ______

L)Race, ethnic or tribal group: ______

M)Is this child in the U.S.?______

N)If not in U.S., please specify location:______

O)Place of last entry to U.S.:______

P)Date of last entry to U.S. (mm.dd.yyyy): ______

Q)I-94 No. (if any): ______

R)Status when last admitted (visa type): ______

S)What is your child’s current status: ______

T)What is the expiration date of his/her current authorized stay?______

U)If in the U.S., is your child to be included in your asylum application?

  1. Yes____
  2. No_____

Child 3:

A)Alien Registration number (if any):______

B)Passport/ID Card No. (if any):______

C)Marital Status (married/divorced/separated/single)______

D)U.S. Social security number if any:______

E)Complete last name: ______

F)Middle Name: ______

G)First Name: ______

H)Male___ Female___

I)Date of Birth______

J)City and county of birth:______

K)Nationality/Citizenship: ______

L)Race, ethnic or tribal group: ______

M)Is this child in the U.S.?______

N)If not in U.S., please specify location:______

O)Place of last entry to U.S.:______

P)Date of last entry to U.S. (mm.dd.yyyy): ______

Q)I-94 No. (if any): ______

R)Status when last admitted (visa type): ______

S)What is your child’s current status: ______

T)What is the expiration date of his/her current authorized stay?______

U)If in the U.S., is your child to be included in your asylum application?

  1. Yes____
  2. No_____
  1. Parents:Please provide the following information for your parents:

Mother:

A)Full Name______

B)City/Town/Country of Birth______

C)Deceased: Yes___ No___

D)Current Location______

Father:

A)Full Name______

B)City/Town/Country of Birth______

C)Deceased: Yes___ No___

D)Current Location______

  1. Siblings: If applicable, please provide the following information for allsiblings.

Sibling 1:

A)Full Name______

B)City/Town/Country of Birth______

C)Deceased: Yes___ No___

D)Current Location______

Sibling 2:

A)Full Name______

B)City/Town/Country of Birth______

C)Deceased: Yes___ No___

D)Current Location______

Siblings 3:

A)Full Name______

B)City/Town/Country of Birth______

C)Deceased: Yes___ No___

D)Current Location______

GENERAL BACKGROUND QUESTIONS

  1. Do Either You or Your Spouse Have a Grandparent Who Was Born in the U.S. or Became a Naturalized Citizen? Yes___ No___
  1. Has An Immigrant (Green Card or I-130) Petition Ever Been Filed for:

A)You? Yes___ No___

If Yes, Please State When, Where, What Type, and the Status of that Application______

B)Your Spouse? Yes___ No___

If Yes, Please State When, Where, What Type, and the Status of that Application______

C)Children? Yes___ No___

If Yes, Please State When, Where, What Type, and the Status of that Application______

  1. Has a Labor Certification Ever Been Filed for You, Your Spouse, or Children?

Yes___ No___

If Yes, Please State When, Where, What Type, And the Status of that Application.

______

  1. Have You or Your Spouse Ever Worked for the United States Government, Including the Military? Yes___ No___

EDUCATION AND EXPERIENCE

23.EDUCATION: Please provide us with the following information about your education, beginning with the most recent (attach addendum if necessary):

1.

A) Name of School: ______

B) Type of School:______

C) Location (address):______

______

D)Attendance dates: From (Mo/Yr)______To (Mo/Yr)______

2.

A) Name of School: ______

B) Type of School:______

C) Location (address):______

______

D)Attendance dates: From (Mo/Yr)______To (Mo/Yr)______

3.

A) Name of School: ______

B) Type of School:______

C) Location (address):______

______

D)Attendance dates: From (Mo/Yr)______To (Mo/Yr)______

4.

A) Name of School: ______

B) Type of School:______

C) Location (address):______

______

D)Attendance dates: From (Mo/Yr)______To (Mo/Yr)______

PERSONAL BACKGROUND (PLEASE ANSWER ALL QUESTIONS)

24.Have You Ever:

A)Made an Incorrect or Fraudulent Statement or Misrepresented a Fact to Obtain or Try to Obtain Any Visa or Immigration Benefit from the U.S., Including Entry Into the U.S.? Yes___ No___

If Yes, Please Provide Additional Information.

______

B)Been Treated for A Mental Disorder, Mental Retardation, Drug Addiction, or Alcoholism? Yes___ No___

If Yes, Please Provide Additional Information.

______

C)Been Given a Citation? Yes___ No___

If Yes, Please Provide Additional Information.

______

D)Been Given a Ticket? Yes___ No___

If Yes, Please Provide Additional Information.

______

E)Been Given Probation? Yes___ No___

If Yes, Please Provide Additional Information.

______

F)Been Convicted or Confined In a Jail or Prison? Yes___ No___

If so, Was It for Political Reasons? Yes___ No___

If Yes, Please Provide Additional Information.

______

G)Worked Without Authorization? Yes___ No___

If Yes, Please Provide Additional Information.

______

H)Overstayed Any U.S. Visa, or Otherwise Violated Your Visa Status?

If Yes, Please Provide Additional Information.

______

H)Been Convicted of Any Crime Either in the U.S. or Anywhere in the World? Yes___ No___

If Yes, Please Note Previous Convictions and Include Date and Place of Final Dispositions if Available______

______

______

I)Been Involved with Drugs or Narcotics Anywhere in the World? Yes___ No___

If Yes, Please Provide Additional Information.

______

J)Been a Victim of Domestic Violence? Yes___ No___

If Yes, Please Provide Additional Information.

______

K)Been the Victim of a Crime in the U.S. or Assisted in the Investigation or Prosecution of a Crime against you or Another Person? Yes___ No___

If Yes, Please Provide Additional Information.

______

25.Have You Ever Been Required to Appear in Court? Yes___No___.

If Yes, When, Where, and What Was the Final Result?

______

26. Have You Ever Been Required to Appear in a Criminal Proceeding?

If Yes, When, Where, and What Was the Final Result?

______

(Please provide copies of all documents regarding all prior contact with the Courts.)

27. Have You Ever Been Required to Appear in U.S. Immigration Court or Been the Subject of U.S. Removal, Deportation or Exclusion Proceedings? Yes___ No___

If Yes, When, Where, and What Was the Final Result?

______

28. Have You, Your Spouse, or Children Been Questioned or Arrested by the Immigration Service? Yes___ No___

If Yes, When, Where, and What Was the Final Result? ______

(Please provide copies of all documents regarding all prior contact with the immigration Service.)

30.Have You or Your Spouse ever been in the US on a J-1 Visa? Yes___ No___

If Yes, Then on Which Program, and were either of you Subject to the Requirement That You Return to Your Home Country for Two Years?

______

______

31.Have you and your Family Filed all Your U.S. Income Taxes? Yes___ No___

Please sign and date this Questionnaire to confirm that the contents are true and correct to the best of your knowledge and belief

______

SignatureDate

How did you hear of us?

  1. Internet Search
  2. Search through the American Immigration Lawyers Association (AILA) 
  3. Referral from another attorney
  4. Name of attorney______
  5. Referral from previous Grossman Law, LLC client
  6. Name of client______
  7. Other. Please specify______

Please return your completed questionnaire to Grossman Law, LLC, Attn: Sandra Grossman, 110 N. Washington Street, Suite 350, Rockville, MD 20850. You may also email a copy of the questionnaire to Sandra Grossman at or via fax at (240)453-0915.