CLIENT QUESTIONNAIRE (Family Cases – Immigrant Visa)

The information you provide is extremely important so please read the questions carefully and fill out this
form completely and accurately. Do not leave any spaces blank, if a question does not apply to you, cross it
out or put ”N/A”. As always, all the information you supply us will be kept STRICTLY CONFIDENTIAL.
Upon completing your questionnaire, please return the questionnaire by mail, fax, email, or drop off.
Incomplete questionnaires will not be accepted and will be returned to you for completion.

INFORMATION ABOUT PERSON BEING PETITIONED/SPONSORED ( )

1. Complete name:
Last Middle First

2. Other names used (including name before marriage):

3. Current Address: Street No. & Name:

City/State/Zip Code:

4. Contact & Social Medial Information (Continue on a Separate Piece of Paper if necessary)
Current & Best Telephone Number: ( )
All Telephone Numbers used during the last 5 years: ______________________________
Current E-mail:_______________________________
All E-mail addresses used during the last 5 years: ________________________________

5. Date of birth:

6. Place of birth:
City State/Province Country

7. Current Citizenship:
8. SS No.:

9. Alien No.(if any) 10. Sex: male female

11. Marital status: married widowed divorced single (never married)

12. Personal Characteristics: Height Weight Eyes Color Hair Color

13. Location of any scars or birth marks:

14. What languages do you read, write, speak:

15. All social media (ex, FaceBook, Twitter, Instagram, etc.) addresses, identifiers, names used by
you for the last ten years:
_____________________________________________________________________________
_____________________________________________________________________________

LIST ALL ADDRESSES WHERE YOU HAVE LIVED SINCE BIRTH

City State/ From To
Street No. & Name Country (Month/Yr) (Month/Yr)
                   / Present
(NOW)
                  / /

                  / /

EMPLOYMENT DURING THE LAST 10 YEARS (starting with most recent).

Are you currently employed? Yes No

Employer's
Co. City & From To
Name Work Address State (Month/Yr) (Month/Yr) Occupation
Present
                  / (NOW)      
                  / /      
                  / /      

List all Schools attended (Elementary, High School, Universities, Colleges, or Trade )
From To
School Name City/Country Major (Month/Yr) (Month/Yr) Degree
Present
                  / (NOW)      
                  / /      
                  / /      
                  / /      

CHILDREN INFORMATION
HOW MANY CHILDREN DO YOU HAVE?
Information about each of your children:

Child’s full name: Date of Birth: / /

Country of Birth Citizenship
A# Current Address:

Child’s full name: Date of Birth: / /

Country of Birth Citizenship
A# Current Address:

Child’s full name: Date of Birth: / /

Country of Birth Citizenship
A# Current Address:

Continue on blank of paper if more than three children.

PARENTAL INFORMATION

INFORMATION ABOUT YOUR PARENTS

Your Father’s full name:
His Date of Birth:
City & Country of Birth:
Where does he currently live? (City/Country):_______________________
If deceased, year of death: ________________________

Your Mother’s name before she was married:

Her Date of birth:
City & Country of Birth:
Where does she currently live? (City/Country): ______________________
If deceased, year of death: _________________________

OTHER FACTORS:
1. Have you ever been arrested, detained, or questioned by the police or the INS,
or convicted of a crime?  Yes  No

2. Have you ever committed a crime for which you were not arrested?  Yes  No

3. Have you ever been deported, removed, been in deportation proceedings  Yes  No
or allowed to voluntarily depart the U.S.?

4. Practiced, used, or been involved in any of the following:

alcohol abuse / alcoholism?  Yes  No
polygamy?  Yes  No
prostitution?  Yes  No
illegal entry of foreigners?  Yes  No
drugs (narcotics)?  Yes  No
illegal gambling?  Yes  No

5. Have you given false testimony for immigration benefits?  Yes  No

6. Have you ever filed documents or received any notices from the INS,
or the American Consulate?  Yes  No

7. Have you ever claimed to be a U.S. Citizen or voted in an U.S. Election?  Yes  No

IS THERE ANY OTHER INFORMATION ABOUT YOU OR YOUR FAMILY MEMBERS THAT YOU BELIEVE IS
IMPORTANT AND IS NOT ON THIS QUESTIONNAIRE?  Yes No
IF YES, PLEASE INFORM OUR OFFICE.