Post-Conviction Relief for Immigrants

Chapter

Summary Table of Contents

Appendix A3. Intake Form

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Intake Form

· Please write clearly or type your responses.

· All the information you provide on this form is confidential and will not be released to anyone without your permission.

1. Today’s Date

Information About Person Completing this Form:

2. Your Name

LAST FIRST

3. Your Relation to Client

4. Your Home Number

( )

5. Your Work Number

( )

Client* Information (Information About Person Who Has an Immigration Problem Because of a Criminal Case)

6. Name

LAST FIRST

7. Who referred you to our office?

8. Home Phone Number

( )

9. Work Phone Number

( )

10. Address

11. Date of Birth

12. Immigration File No.

A__________________________

Street Address Apt. No.

13. Client’s Social

Security Number

- -

City State Zip Code

14. Client’s Occupation

15. Name of Employer

Client’s Current Criminal and Immigration Situation

16. Client is currently

q Not in custody

q In criminal custody

q In INS custody

CDC* #_________

17. If in custody, what is the scheduled release date?

18. Do you currently have an immigration attorney?

q No

q Yes è

Name________________________________________

Phone ( )

19. Are you currently in INS deportation proceedings?

q No

q Yes è

Next Immigration Court Date:

____________________

20. Are you currently in criminal proceedings?

q No

q Yes è

Next Criminal Court Date: _______________

21. Briefly describe the immigration problem you are having.

Client’s Immigration History

22. In what country were you born?

23. What is your country of citizenship?

24. What language(s) do you speak?

25. Please select the item below which best describes your immigration status.*

Date Obtained

Expiration Date

q Undocumented*

q Legal Permanent Resident* (Green Card Holder)

/ /

q Visa* Holder è

Type

/ /

q Work Permit* Holder

/ /

q Amnesty Applicant*

/ /

q Other è

Describe

/ /

26. On what date did you first enter the U. S.?

27. With what documents did you first enter the U.S. , if any?

28. Please 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.

Departure Date Return Date Purpose of Trip

29. If you have ever appeared in INS Court, provide the date on which you appeared.

30. If you have ever been ordered deported by an immigration judge, provide the date.

31. If you have previously appeared in INS court, briefly explain why.

32. Have you ever received a waiver of deportability (212(c)relief* or cancellation of removal?*

q No

q Yes è When?___________

33. Have you ever received suspension of deportation?*

q No

q Yes è When?________

34. Are you married?

q No

q Yes

è For how long? ______

Immigration Status of Spouse

35. Do you have any children?

q No

q Yes

è How many? ________

Immigration Status of Children

36. Do you have any close relatives in the U.S.?

q No

q Yes

è How many? ________

Immigration Status of Relatives

37. Is/was your mother a United States Citizen*?

q No

q If Yes è

q By Birth

q Naturalized to become a U.S. Citizen on the following date

38. Is/was your father a United States Citizen?

q No

q If Yes è

q By Birth

q Naturalized to become a U.S. Citizen on the following date

39. Are/were your grandparents United States citizens?

q No

q Yes

40. Are/were your spouse’s parents United States citizens?

q No

q Yes

41. Are/were your spouse’s grandparents United States citizens?

q No

q Yes

42. Have your parents or a spouse ever abused you?

q No

q Yes

43.

44. Do you own a home in the U.S. or, are you in the process of buying a home in the U.S.?

q No

q Yes

45. Do you own a business in the U.S.?

q No

q Yes

46. Would you fear for your life if you had to return to your country of citizenship?

q No

q Yes

è Briefly explain why

Criminal Record Information

46. Please list every arrest*. Begin with the oldest offense* and end with the most recent.

EXAMPLE Petty Theft

PC 123.4

2003

Alameda, CA

Arrest No 1 Description of Offense

Statute* (code number)

Year

County & State

Arrest No 2 Description of Offense

Statute* (code number)

Year

County & State

Arrest No 3 Description of Offense

Statute* (code number)

Year

County & State

Arrest No 4 Description of Offense

Statute* (code number)

Year

County & State

Arrest No 5 Description of Offense

Statute* (code number)

Year

County & State

Arrest No 6 Description of Offense

Statute* (code number)

Year

County & State

Conviction Information Sheet Note: Make extra copies of this page before filling it out.

Please complete a Conviction Information Sheet for every conviction you have received, making additional copies of this form as needed. Please start with the oldest conviction and end with the most recent.

47. Conviction Number (Office Use Only)

48. Date of Arrest

49. City and State of Arrest

50. County of Arrest

51. Please give a brief description of the events that led to your arrest.

52. Please list all the charges* brought against you in this incident.

Charge No 1

Charge No 2

Charge No 3

Charge No 4

53. What court did you appear in?

q Municipal Court

q Superior Court

q Other (Name):

q Federal Court

_________________

City

County

___________________________________

54. What name was used for you on the court documents?

55. Were there codefendants* involved?

q No

q Yes è

How many? ____________

56. Did you go to trial*?

q No

q Yes è Days in Trial_______

57. If you went to trial,

was it decided by

q Jury

q Court

58. Did you appeal*?

q No

q Yes è

Result?_________________________________________________________

59. If you did not go to trial, what plea* did you give?

q Guilty

q No Contest/Nolo Contendre

60. On what date did you enter your plea?

61. Please list all the charges you were convicted of in this particular case.

1. Description of charge – conviction

Code Section

2. Description of charge – conviction

Code Section

3. Description of charge – conviction

Code Section

4. Description of charge – conviction

Code Section

62. On what date did you receive your sentence*?

63. What was your sentence?

64. Did you serve time in

q County Jail

q State Prison

è How long____

Release

Date______

65. Did you receive:

q Probation

q Parole

è For how long_________

66. Did you complete probation or parole without a violation?

q Yes

q No èIf revoked, please fill out a separate Criminal Information Sheet for this incident.

67. If you violated probation/parole, what did you do?

68. What type of attorney did you have in the original court proceedings?

q Private Attorney

q Public Defender

q Court Appointed Attorney

Attorney’s Name and Phone Number

( )

69. Did your attorney tell you about the exact immigration problems that this criminal conviction could cause, such as deportation, exclusion, denial of amnesty, etc, before you gave a guilty or no contest plea?

q No

q Yes

70. Exactly what did your attorney tell you about the possible immigration problems?

71. Did the judge tell you about the possible immigration problems this criminal conviction could cause for you when you entered your plea of guilty or no-contest?

q No

q Yes

72. Exactly what did the judge say?

73. Did you have an interpreter in court?

q Yes

q No èDid you need an interpreter?

q Yes

q No

74. If you had an interpreter, did you have any difficulty understanding the translation?

q Yes

q No