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DACA Questionaire

DACA  (DEFERRED ACTION FOR CHILDHOOD ARRIVALS) QUESTIONNAIRE AND DOCUMENT REQUEST

 

DACA_Questionaire.docx

DACA_Questionaire.pdf

 

Williamsport Lawyers

 

Please print clearly the following information and return it to:

RUDINSKI ORSO AND LYNCH

339 N Market Street

Williamsport Pa 17701

Phone 570.321.8090

Fax: 570.326.9110

Email: Contact@pa-law-firm.com

 

In order to properly advise you, we rely on the accuracy and completeness of the information we receive from or on behalf of you. Rudinski Orso and Lynch is not liable for any negative legal and/or immigration consequence or consequences that result due to the receipt and/or submission of false, misleading, inaccurate, or incomplete information from or on your behalf. The information and documents requested in this DACA Questionnaire should not be shared with anyone except for a licensed lawyer that you are seeking to employ in connection with legal services.

The completion and/or submission of this DACA Questionnaire and Document Request does not in itself create an attorney-client relationship with Rudinski Orso and Lynch. Inorder for any legal services to be performed in connection with this DACA Questionnaire and Document Request, and/or for the performance of legal services concerning any other issue, a separate fee agreement will need to be reached with Rudinski Orso and Lynch. Payment of attorney and filing fees also must be paid in full, or in accordance with the terms of the separate fee agreement, in order for any legal work to commence.

For questions that do not apply to you, please print N/A or Not Applicable in the space provided for the answer to the question. If you do not know the answer to a particular question, please print Unknown.

BACKGROUND AND CONTACT INFORMATION:

Your complete name (last name, first name, middle name):

____________________________________________________________

Date of birth:   

____________________________________________________________

Place of birth (city, Province or State, and Country):

____________________________________________________________

List any other names or aliases that have previously used, or that you currently use (last name, first name, middle name):

____________________________________________________________

Home telephone number:
____________________________________________________________

Work telephone number: Email address:

____________________________________________________________

____________________________________________________________

Social security number (if you legally possess the same):

____________________________________________________________

A# (Alien Number):
____________________________________________________________

Name of spouse (last, first, middle):

____________________________________________________________

Names of child(ren), date(s) of birth, and place(s) of birth:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

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Contact information for any other family member in the United States (name, relationship to you, address, telephone number, email address):

____________________________________________________________

____________________________________________________________

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____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

 

ARRIVAL HISTORY AND CURRENT STATUS

Did you arrive in the United States on or before June 15, 2007?: 
____________________________________________________________

 

Have you been continuously living in the United States since June 15, 2007?:

____________________________________________________________

Please provide the starting and ending date/month/year of each address you lived at since you first came to the United States (start with your current United States address (street number and name, apartment number, city, state, and zip code):

Address                                       Move In Date                   Move Out Date

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

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Date and place of each arrival and departure from the United States:

____________________________________________________________

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Place of your last entry into the United States (city and date):

____________________________________________________________

Date, month and year you last entered the United States:

____________________________________________________________

How did you enter the United States? (as a visitor, entered without inspection etc):

____________________________________________________________

Did you arrive in the United States prior to your 16th birthday?:

____________________________________________________________

Have you continuously resided in the United States for 5 or more years?:

____________________________________________________________

Have you ever had any type of legal status entering the United States? If so, please provide the following information:

1) What was your prior USCIS Status?:

____________________________________________________________

2) Date of expiration of your prior USCIS:

____________________________________________________________


3) What is your current USCIS Status?:

____________________________________________________________

 

4) What is the date of expiration of your current USCIS status?:

____________________________________________________________

 

5) Do you have an I-94 card number?.  If so please provide that number:

____________________________________________________________

Are you currently in removal proceedings?:

____________________________________________________________

Were you ever in removal proceedings that were terminated?:

____________________________________________________________

Were you ever in removal proceedings that were administratively closed?:

____________________________________________________________

Are you currently subject to a final order of removal?

____________________________________________________________

If you answered yes to any questions concerning removal proceedings, please provide the date and location of the proceedings:

____________________________________________________________

 

EDUCATIONAL HISTORY

Your current educational status (in school, GED, High School graduate):

____________________________________________________________

The name and location of any school that you are currently attending or where you received your degree or diploma:

____________________________________________________________

Date of your last attendance in school:

 ____________________________________________________________

Date of graduation or receipt of GED:

____________________________________________________________

 

UNITED STATES MILITARY HISTORY

Branch of your United States military service (Army, Navy, Air Force, Marines, Coast Guard, etc.):

____________________________________________________________

Beginning and end dates of service:

____________________________________________________________

Your current United States military status (active duty, reserve duty, honorable discharge, general discharge, dishonorable discharge, etc.):

____________________________________________________________

 

CRIMINAL HISTORY

Have you been arrested, charged, indicted, and/or convicted of a crime in the United States or outside of the United States?:

____________________________________________________________

If so, please provide the following information for each arrest, charge, indictment, or conviction that you received. 

1)      The name or the offense or offenses (for example: retail fraud, assault, drunk driving, etc.):

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

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2)     The place where you were arrested (city, State, country):

____________________________________________________________

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3)     The name of any police agency, or law enforcement agency involved (for example: Michigan State Police, Detroit Police, FBI, etc.)

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________
 

4)     The name and address of any Court you attended:

5)     The result of any of the above stated Criminal History. Date or dates of any convictions, and charge convicted of. Dates of any acquittals:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

6)     Did you receive any special status in the law to avoid a conviction, such
as a diversion program or a plea under advisement? If so, please provide an explanation as to what occurred?

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________
 

7)     Are you currently on bond, probation or parole for any criminal offense? If so, please provide information as to your current circumstances, including the Court location, and the nature of the allegation or conviction:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________


 

GROUP OR ASSOCIATION HISTORY

Have you ever engaged in or do you continue to engage in or plan to engage in terrorist activities?

____________________________________________________________

Are you now or have you been a member of a gang?

____________________________________________________________

Have you ever engaged in, ordered, incited, assisted or otherwise participated in any of the following activities?:

1. Acts involving torture, genocide, or human trafficking?:

____________________________________________________________

2. Acts of homicide or murder?:

____________________________________________________________


3. Acts that lead to the severe injury of another person?:

____________________________________________________________

4. Any type of criminal sexual conduct, attempted criminal sexual conduct, or a threat of criminal sexual conduct?:

____________________________________________________________

 

 

FINANCIAL INFORMATION

Your total monthly income:

____________________________________________________________

The total current value of your assets (car, house, etc.)?:

____________________________________________________________

Your total monthly expenses:

Rent: $ ______________________________;

Utilities $_____________________________;

Phone $ _____________________________;

Gas: $_______________________________;

Food $ ______________________________;

Medical $ ____________________________;

Tuition: $_____________________________;                

Childcare $___________________________;            

Clothes $ ____________________________;

Insurance (auto etc): $__________________;

Any other expenses: $__________________;

Please specify any other expenses in the space provided below:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________
 

ENGLISH LANGUAGE

Do you speak, read and write English?:     
____________________________________________________________

 

If not, who can translate the above information to you from your native Language to English? ( please provide the translator’s name and telephone number): 
____________________________________________________________

 

 

 

 

PLEASE PROVIDE A COPY OF THE FOLLOWING ITEMS TO RUDINSKI ORSO AND LYNCH:

1.     Filing fee $465 Payable to US. Department of Homeland Security;

2.     Two passport photos;

3.     Birth certificate with English translation)

4.     Passport, especially stamps showing your travel dates in and outside the
United States;

5.     Any Identification documents issued by your home country or in the United States

6.     School records;

7.     Medical records (doctors, hospitals, immunizations, etc)

8.     Financial records (bills, receipts, etc);

9.     School report cards;

10. School transcripts;

11. Employment records (i.e. pay stubs);

12. Diploma

13. GED

14. Military service records (i.e. military health records, military
attendance);

15. Tax records;

16. Bank statements;

17. Utility bills in your name;

18. Your children’s birth certificate in the United States;

19. Your automobile records;

20. Mortgage, rental agreements, lease agreements;

21. Letters with postmarks;

22. If applicable a copy of the criminal record; We will also need any arrest records, charging documents, dispositions and sentencing records.

23. If applicable a copy of the removal record or immigration court
paperwork;

24. Any other documents which would prove: 

           A) your presence in United States before the age of 16 years;

       B) your continuous residence in United States since June 15, 2007, up to the present time;

       C) your physical presence in United States on June 15, 2012;

       D) that you are currently in school, graduated or obtained a certificate of completion from high school, or have obtained a GED;

       E) that your are an honorably discharged veteran of the Coast Guard or Armed Forces of the United States;

 

 

 

 

I declare under the penalty of perjury under the laws of the United States, that
the foregoing is true and correct

Signature of Applicant:


____________________________________________________________

Printed name of Applicant:

____________________________________________________________

Date:

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