You are on page 1of 7

PERMANENT RESIDENCE QUESTIONNAIRE

Please complete this questionnaire as thoroughly as possible and leave no blank spaces. If a matter is not applicable to you or if a
question does not apply to your situation, simply indicate either “N/A” or “None.” Please note that we cannot begin the immigrant
process until all of the information requested below has been provided and you have signed the attestation, acknowledgement and
agreement included on Page 7 and payment is remitted

Please return the completed questionnaire by email to prerna@lallegal.com or by mail to ATTN: Prerna Lal (Lal Legal), 2001
Addison Street, Ste 300, Berkeley, CA 94704.

PERSONAL DATA (BENEFICIARY)


First Name (Given): Middle Name:
Last Name (Family): Maiden Name (before marriage):
Preferred email address: Alien Number (A#), if applicable:
Permanent foreign address:
Home phone: Cell phone:
Date of Birth (month/day/year): Current age: Gender (male/female):
Country of Birth: City of Birth:
Country of Present Citizenship: State/Province of Birth:
U.S. Social Security number:
Country of Passport Issue: Passport Issue Date (month/day/year):
Passport Number: Passport Expiration Date (month/day/year):
Marital status: Number of children:
Height: Weight:
Hair Color: Eye color:

IMMIGRATION HISTORY
Current status in the U.S.: Current I-94#
Date of I-94 issue: Date of I-94 expiration:
Date and place of last entry into the U.S.: Visa category under which entry was made:
Date of initial entry into U.S.: Visa category under which initial entry was made:
Has an Immigrant Petition (I-140 or I-130) ever been filed on your behalf? (Y/N):
If an I-130 Immigrant Petition has been filed on your behalf, please provide the name of the sponsor that petitioned for you, the date the
the I-130 was filed, and
location where filed:
Have you ever filed an application for permanent residence (I-485 or OF-230 or DS-230)? (Y/N)? If yes, attach details/documents.
Have you ever held an Employment Authorization Document (EAD)? (Y/N)? If yes, attach copies.

DM2\2672371.1
PR QUESTIONNAIRE Page 2

MARRIAGE DATA
Including your current marriage, how many times have you been married:
CURRENT SPOUSE:
Spouse’s Name (First, Middle, LAST):
Date of Marriage:
Spouse’s Maiden Name (if applicable):
Place of Marriage:
Spouse’s Current Immigration Status:  US Citizen  Lawful Permanent Resident
Spouse’s Date of Birth:

IF YOU WERE PREVIOUSLY MARRIED, PROVIDE THE FOLLOWING REGARDING ALL PRIOR SPOUSES:
Name of prior spouse (First, Middle, LAST): Date of Marriage:
Prior Spouse’s Date of
Birth:
Place of marriage: Place marriage was Date marriage was How marriage was terminated
terminated: terminated: (divorce, death, annulment) :
Name of prior spouse (First, Middle, LAST): Date of Marriage:
Prior Spouse’s Date of
Birth:
Place of marriage: Place marriage was Date marriage was How marriage was terminated
terminated: terminated: (divorce, death, annulment) :
BENEFICIARY’S BIOGRAPHICAL DATA
MOTHER:
First Name (Given): Middle Name: Last Name (Family): Maiden Name
(name before marriage):

Date of Birth Place of Birth (city/country): Place of current resident (city/country) – if deceased, so state :
(month/day/yr):

FATHER:
First Name (Given): Middle Name: Last Name (Family): Maiden Name
(name before marriage):

Date of Birth Place of Birth (city/country): Place of current resident (city/country) – if deceased, so state:
(month/day/yr):

INFORMATION ABOUT YOUR CHILDREN


CHILDREN:
1. First Name (Given): Middle Name: Last Name (Family): Gender (male/female):

Date of Birth Current City of Birth: Country of Birth: Country of Present Citizenship:
(month/day/yr): age:

Alien No.: Country Issuing Passport: Passport No: Applying with you? Yes/No:

2. First Name (Given): Middle Name: Last Name (Family): Gender (male/female):

Date of Birth Current City of Birth: Country of Birth: Country of Present Citizenship:
(month/day/yr): age:

Alien No.: Country Issuing Passport: Passport No: Applying with you? Yes/No:

Please make copies of this page if you require additional space for information regarding your children. Attach all additional pages to this questionnaire.
PR QUESTIONNAIRE Page 3

PLEASE NOTE

You and your family are responsible for your immigration status in the United States. You must always be aware of your I-94
and I-797 expiration dates. Should your marital or parenthood status change, please notify this office immediately so that we
may properly document the change in our files and take any additional filing steps that may be necessary.

RESIDENCE DATA (BENEFICIARY)


List complete addresses, starting with most recent residence (including zip code if possible) for the last 5 years. On dates for length of
stay, indicate month and year. (Attach separate sheet as necessary.)
Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Last residence outside the U.S., if not listed above (*REQUIRED*)


Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

EMPLOYMENT HISTORY (BENEFICIARY)


List all jobs starting with your current position. List different positions for same employer separately. Please provide information for the
past five (5) years. Please explain any breaks in employment on a separate sheet of paper.
Name of Employer: Employer’s Address:
Job Title: Dates Employed (month/yr): From To Hours/week:

Name of Employer: Employer’s Address:


Job Title: Dates Employed (month/yr): From To Hours/week:

Name of Employer: Employer’s Address:


Job Title: Dates Employed (month/yr): From To Hours/week:
PR QUESTIONNAIRE Page 4
Name of Employer: Employer’s Address:
Job Title: Dates Employed (month/yr): From To Hours/week:

Name of Employer: Employer’s Address:


Job Title: Dates Employed (month/yr): From To Hours/week:

Last Employment Outside the U.S. (*REQUIRED*):


Name of Employer: Employer’s Address:
Job Title: Dates Employed (month/yr): From To Hours/week:

ORGANIZATIONS (BENEFICIARY)
List any current or past memberships or affiliations in any political organization, association, fund, foundation, party, club, society or
similar group since your 16th birthday. If none, write “None”. Also include any military service.
Name and Type of Organization Location (City/Country) Role (member. etc.) Dates of Membership
From To
From To
From To
From To
From To
From To

VIOLATIONS/OTHER ISSUES (BENEFICIARY)


Have you ever been arrested or convicted in the U.S. or any foreign country (not including any traffic violations)? Yes No
If yes, give details (Date/Place Arrested).
Charge: Disposition:
Note: Complete records of arrest or conviction will be needed if you are sponsored for Permanent Residence.
There are certain types of situations which may present unusual problems and require special procedures to obtain entry to/permanent
residence in the United States. Are any of the following applicable to you?
Yes No
Have you ever been subject to the J-l related 2-year foreign residence requirement?
Have you ever been afflicted with a communicable disease of public health significance, a dangerous physical
disorder, or a mental disorder of any kind?
Have you ever been a drug abuser or addict, or trafficker of controlled substances?
Yes No
Have you ever been a prostitute or procurer of prostitution?
Have you ever sought to obtain or assisted other to obtain by fraud or willful misrepresentation a U.S. visa, entry into
the United States, or any U.S. immigration benefit?
Do you seek to enter the United States to engage in any unlawful activity?

Have you ever ordered, incited, assisted, or otherwise participated in the persecution of any person because of race,
religion, national origin, or political opinion under the control, direct or indirect, of the Nazi Government of Germany, or
of the government of any area occupied by, or allied with, the Nazi Government of Germany, or have you ever participated
in genocide?
Have you or any member of your immediate family ever been in exclusion or deportation proceedings, or been
ordered excluded or deported from the United States?
Have you ever done anything which violates the terms of your U.S. nonimmigrant status?
If you answered “yes” to any of the above questions, please attach a separate sheet describing in detail the reason for your answer.

PERSONAL DATA (PETITIONER)


PR QUESTIONNAIRE Page 5

First Name (Given): Middle Name:


Last Name (Family): Maiden Name (before marriage):
Preferred email address: Alien Number (A#), if applicable:
Home phone: Cell phone:
Date of Birth (month/day/year): Current age: Gender (male/female):
Country of Birth: City of Birth:
Country of Present Citizenship: State/Province of Birth:
Height: Weight:
Hair Color: Eye color:

IF YOU WERE PREVIOUSLY MARRIED, PROVIDE THE FOLLOWING REGARDING ALL PRIOR SPOUSES:
Name of prior spouse (First, Middle, LAST): Date of birth: Date of Marriage:

Place of marriage: Place marriage was Date marriage was How marriage was terminated
terminated: terminated: (divorce, death, annulment):

Name of prior spouse (First, Middle, LAST): Date of birth: Date of Marriage:

Place of marriage: Place marriage was Date marriage was How marriage was terminated
terminated: terminated: (divorce, death, annulment):
(Attach additional sheets if more space is needed.)
Note: Documentation of termination will be required at the time your application for permanent residence is prepared.

PETITIONER’S BIOGRAPHICAL DATA


MOTHER:
First Name (Given): Middle Name: Last Name (Family): Maiden Name
(name before marriage):

Date of Birth Place of Birth (city/country): Place of current resident (city/country) – if deceased, so state :
(month/day/yr):

FATHER:
First Name (Given): Middle Name: Last Name (Family): Maiden Name
(name before marriage):

Date of Birth Place of Birth (city/country): Place of current resident (city/country) – if deceased, so state:
(month/day/yr):

RESIDENCE DATA (PETITIONER)


List complete addresses, starting with most recent residence (including zip code if possible) for the last 5 years. On dates for length of
stay, indicate month and year. (Attach separate sheet as necessary.)
Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):
PR QUESTIONNAIRE Page 6

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

Street Address:
City/State/Zip Code: Country: From(month/yr): To(month/yr):

EMPLOYMENT HISTORY (PETITIONER)


List all jobs starting with your current position. List different positions for same employer separately. Please provide information for the
past five (5) years. Please explain any breaks in employment on a separate sheet of paper.
Name of Employer: Employer’s Address:
Job Title: Dates Employed (month/yr): From To Hours/week:

Name of Employer: Employer’s Address:


Job Title: Dates Employed (month/yr): From To Hours/week:

Name of Employer: Employer’s Address:


Job Title: Dates Employed (month/yr): From To Hours/week:

Name of Employer: Employer’s Address


Job Title: Dates Employed (month/yr): From To Hours/week:
Name of Employer: Employer’s Address
Job Title: Dates Employed (month/yr): From To Hours/week:
FINANCIAL INFORMATION & TAX HISTORY (PETITIONER)
Employment Status:
Occupation:
Self-employed as:
Retired from: (provide company name and date retired)

Unemployed since:
Current Individual Annual Income:

During the past 3 years, have you received income (i.e., wages, rents, interests, dividends, royalties, etc.) from sources in the U.S.?
Yes No
During the past 3 years, have you filed a US Individual Tax Return (i.e., Forms 1040, 1040A, 1040EZ, etc.)?
Yes, I filed a joint return that included income from my spouse and myself for tax year .
Yes, I filed a single/separate return for tax year .
Yes, I filed a joint return that includes only my income for tax year . No.
Please provide your total income or adjusted gross income as reported on your federal tax return for the last three years:
Year: Total Income:
Year: Total Income:
PR QUESTIONNAIRE Page 7
Year: Total Income:

Household Size:
Number of persons currently residing at your place of residence (excluding you and your spouse )
List names of all persons residing with you or whom you claim as a dependent on your tax return:

ASSET INFORMATION
Balance of all savings and checking accounts $
Cash Value of all stocks, bonds, and certificates of deposit $
Life Insurance value $
Personal Property value $
Net cash value of real estate holdings (current assessed value
less any mortgage debt) $

Address of real estate property owned:

Attestation, Acknowledgement and Agreement

[If submitting this questionnaire by electronic mail, please check the appropriate boxes below to acknowledge your agreement and
type your name on the signature line. Please also type the date beside your name.]

I hereby attest the information I have provided herein is true and correct to the best of my knowledge and belief.

I hereby agree to and accept the terms of representation by LAL LEGAL, acknowledge that such representation relates to a representation of
multiple parties and waive any conflict of interest and confidentiality arising from such multiple representations as set forth herein.

Signature Date

DO NOT WRITE BELOW THIS AREA FOR COMPANY USE ONLY

Date Questionnaire Received: Received by:

Signature: