QUESTIONNAIRE Foreign National Personal Information (Please send a copy of passport for you and your dependents):

Name: DANIEL MELIA FERREIRA

Address: 4550 Kittredge St.

City: Denver State/Province: CO Zip/Postal Code: 80239

Phone #: (720) 384-7633 Email Address: samdanieel82@gmail.com

City and Country of Birth: São Gotardo (MG) - BRASIL

Local de Nascimento

Date of Birth (mm/dd/yyyy): 01/19/1992 Date of Last Entry into the U.S. (mm/dd/yyyy): 11/08/2012
Data da última entrada nos EUA

Class of Admission (i.e. B2, F1, etc.): B1 & B2 Current Immigration Status in the U.S.: FORA DE STATUS
Qual o visto você está hoje Situação atual nos EUA

What process will you do: VAWA

Qual processo você vai fazer

Marital Status: ( ) Single ( x ) Married ( ) Divorced ( ) Widower

Estado civil

Derivatives
Dependentes

Spouse’s Name: Date of Birth: 04/19/1997 Country of Birth: USA

Nome do cônjuge CHLOE MARIE DOWNS
Child’s Name: Date of Birth: Country of Birth:

Child’s Name: Date of Birth: Country of Birth:

Child’s Name: Date of Birth: Country of Birth:

Child’s Name: Date of Birth: Country of Birth:

Child’s Name: Date of Birth: Country of Birth:

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