THE MACSIM FIRM

801 Northpoint Parkway Telephone: 561-899-8184

West Palm Beach, Florida 33407 Facsimile: 561-536-3031

IMMIGRATION INTAKE QUESTIONNAIRE

The informationyou areproviding on this form is confidential andisonlyusedfor our office purposes.

Part A. Today’sdate:

LastName (use completename)

First Name (use complete name)

Address / City / State / Zipcode

( _) TelephoneNumber: Home

( ) TelephoneNumber: Cell

Areyou employed? (yes orno)

Current employer’sname

$ Monthly Income

Emergency Contact Person

( ) TheirTelephoneNumber: Home

( ) TheirTelephoneNumber: Cell

- - _. SocialSecurityNumber

A-

Immigration“A”Number

LanguageSpoken

Spanish?

Other?

Date ofBirth (month-day-year)

Countryof Birth

Marital Status: (Check one) / Single / Divorced
Married / Widow(er)
Race: (Check one) / Hispanic / African-American / Other
Caucasian / NativeAmerican
CurrentImmigration Status:(Check one) / Permanent resident / Without legal status
U.S. citizen / Refugee
DateofALL entries intotheUnited States: Beginningwiththe most recentone / Portof entry / Didyou enterwithinspection?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Tobetterserveyou,pleasedescribewhyyou areheretoday and what kind ofassistanceyou need?

Pleasecheckofftheboxes that apply to you:

Applying for afamilymember?
Isa familymemberapplying foryou?
Interestedin obtainingcitizenship of this country for yourself?
Renewing your work permit?
Are you planning or do you need to travel abroad?
Renewing or replacing yourLegal Permanent Residentcard?
Other
Haveyoualready consulted withanotherlegal provider regarding yourcase? / Yes
Ifyouranswer is ‘yes,”please answerwho,when, and where: / No
Who:
When:
Where:
Do you have any deadlines,such as: / Yes No Court dates
Yes No Filing deadlines
Yes No Other
Haveyou everbeen arrested or incarcerated for anykind ofoffense?
If your answerwas “yes,”then please explain below when,where, for how long, and why? / Yes No
When:
Where:
For how long:
Why:

Part B. List everyaddress whereyou havelivedforthelast fiveyears:

Address / When did youbeginliving there? / When did you leave?
1.
2.
3.
4.
5.

List thelast addressoutsidetheUnitedStateswhereyou livedfor more than oneyear:

Address / When did youbeginliving there? / When did youleave?

List everyplace where youhave worked forthelast fiveyears:

Name and Addressof Company / When did you beginworking there? / When did you stop working there?
1.
2.
3.
4.
5.

Name ofyourparents: Father

Mother

Parent’sdate and placeofbirth: / Date of Birth / Place of Birth
Father
Mother
Where doyour parents live right now? / Father
Mother

Current spouse’s name:

Date ofMarriage:
Place of Marriage:
Spouse’sdateand placeof birth: / Date of Birth / Place of Birth

Name ofex-spouse:

Date ofMarriage:
Place of Marriage:
Date ofdivorce termination:
Place ofdivorce termination:
Ex-spouse’sdate and place of birth: / Date of Birth / Place of Birth
Names of your children / Date of Birth / Place of Birth
Have yousponsored or helpedto sponsor someone else? / Yes No
Ifyouranswer is ‘yes,”pleasegivethename and dateof sponsorship
(below):
Name of personsponsored:
Date ofsponsorship:

Part C.

This part isonly for naturalizationapplicants. If youare notapplying for naturalization,pleasego to

“Part D” to sign.

What is your spouse’s status? Please checkthe box thatapplies:
Legal Permanent Resident
U.S. Citizen
Withoutdocuments
Other
If your spouseis a U.S.citizen,did heor she obtaincitizenship through aU.S.citizen spouse? / Yes
No
When did your spouseobtainthestatus? / Date:
Wheredid yourspouseobtain status / City, State:
Is your spouseor ex-spouse aU.S. Citizen? / Yes No
Isyour spouseor ex-spouseaLegal Permanent Resident? / Yes No
If you answered ‘yes’ tothe abovequestion,did you receive Legal
Permanent Residency thruyour spouseor ex-spouse? / Yes No

Please list each and every trip you made outsideoftheUSAsincebecomingapermanentresident:

When did you leave? / When did you return? / Wheredid you go? / Howmany days were you outside ofthe U.S.?
What is your height? / What is your weight?
What isyour eye color? / What is your haircolor?

Part D. How did youlearn about us? Friend Walk-in Other

I authorize the immigration specialists and/or attorney(s) at The MacSim Firm along with their staff and consultants to assist me in completing this form so that they may determine whether or not they will accept my case.

Client Signature

Date