Immigrant Client Post-Conviction Relief Intake Form

Immigrant Client Post-Conviction Relief Intake Form

Attorney Information

Today’s Date: ______

Name: ______Firm/Organization & location: ______

Contact Phone Number: ______Email Address: ______

Client Information

Client’s Name (LAST, FIRST, MIDDLE): ______

AKA’s: ______

Client’s Contact Phone Number: ______-______-______

Client’s Email Address:______

Client’s Address:______

Client’s A #: ______

What language(s) does the client speak?______

Client’s Current Criminal and Immigration Situation

Is client currently: ⎕Not in Custody ⎕In Criminal Custody? ⎕In Immigration Custody?

If in custody, where? (Name)(County)(State):______

If client is currently in criminal custody, what is the scheduled release date? ______/______/______

Is client currently in deportation or removal proceedings? ⎕No ⎕Yes

If yes, when is the next court date?: ______/______/______

Briefly describe the immigration problem client is facing: ______

______

Does client currently have an immigration attorney? ⎕No ⎕Yes

If yes, Name______Phone #:______

Date(s) you appeared in Immigration Court (if applicable): ______/______/______

Reason you appeared in Immigration Court:______

Date you were ordered deported by Immigration Judge (if applicable): ______/______/______

Date you were actually deported to another country (if applicable): ______/______/______

Did you return to the United States after being deported? ⎕ No ⎕ Yes

If yes, when ______/______/______and with what documents, if any: ______

Date you received a Waiver of Deportability (212(c))* or Cancellation of Removal* or Suspension of

Deportation* (if applicable): ______/______/______

List the date of departure, date of return, and purpose of each trip exceeding 90 days out of the U.S. since your first entry:

(Date of Departure) (Date of Return) (Purpose of Trip)

______/______/______/______/______

______/______/______/______/______

______/______/______/______/______

Immigration History

Date of Birth: ____/____/_____ Date of First Entry Into the U.S.: ____/____/_____ Country of Citizenship:______

With what documents did client first enter the U.S., if any?:______

What is client’s immigration status? (Please select one of the following)

⎕ DACA ⎕ Special Immigrant Juvenile Status⎕ Temporary Protected Status

⎕Legal Permanent Resident  Date LPR granted ___/___/____

Did client receive permanent residence through a family member? ⎕No ⎕Yes If yes, who?______

⎕Other immigration status: Please Describe: ______

⎕ Undocumented ⎕ Unknown

Is client’s mother or father a United States Citizen*? ⎕ No ⎕Yes

If yes, ⎕ By Birth or

⎕ Naturalized to become a U.S. citizen on the following date: ______/______/______

Criminal History Summary

FIRST CONVICTION (If you have more than one conviction, start with the oldest and end with the most recent.)

Date Offense Committed: _____/_____/______City, State, County of Arrest:______

Case Number: ______

What court did you appear in? ⎕ State Court ⎕ Federal Court ⎕ Other court: ______

Date of Plea* / Verdict: _____/______/______

Please select one: ⎕Guilty Plea ⎕ No Contest Plea ⎕Convicted after Trial

Date of Sentence*: ______/______/_____ Date of Release from Custody: _____/______/______

Length of Jail/Prison Sentence: ______Length of probation/parole/PRCS/Mandatory Supervision? ______

Did you appeal* your conviction? ⎕ No ⎕Yes If yes, what was the result of your appeal? ______

Did you complete probation without a violation? ⎕ No ⎕ Yes

SECOND CONVICTION (If you have more than one conviction, start with the oldest and end with the most recent.)

Date Offense Committed: _____/_____/______City, State, County of Arrest:______

Case Number: ______

What court did you appear in? ⎕ StateCourt ⎕ Federal Court ⎕ Other court: ______

Date of Plea* / Verdict: _____/______/______

Please select one: ⎕Guilty Plea ⎕ No Contest Plea ⎕Convicted after Trial

Date of Sentence*: ______/______/______Length of Jail/Prison Sentence: ______

Date of Release from Custody: ______/______/______Length of probation or parole? ______

Did you appeal* your conviction? ⎕ No ⎕Yes If yes, what was the result of your appeal? ______

Did you complete probation without a violation? ⎕ No ⎕ Yes

Please continue on separate page if more than two convictions