Beneficiary Intake

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Current Name

First Name Middle Name Last Name

Beneficiary Other Names

Provide all other legal names, nicknames, aliases, and assumed names.

Contact Information

Email Telephone

US Mailing Address

In Care Of Name Street Address Apt / Ste / Flr Number City State ZIP Code Mailing address is the same as current physical address

Current Address

Select a country to continue address entry.

Country

Street Address Apt / Ste / Flr Number City State ZIP Code Province Postal Code

From Date To Date I have lived at this address for more than 5 years

Prior Addresses

Provide your prior address(es) for the last 5 years.

Permanent Address Outside the US

Country

Street Address Apt / Ste / Flr Number City Province Postal Code

From Date To Date

Last Address Outside the US

Where you lived for at least 1 year.

Country

Street Address Apt / Ste / Flr Number City Province Postal Code

From Date To Date

Describe Yourself

Sex Ethnicity Race Height (ft) Height (in) Weight (lbs) Eye Color Hair Color

Financial Information

Expected Annual Income

Current Employment

Current Employment Status

Employer Name Occupation Country

Employer Street Address Apt / Ste / Flr Number City State ZIP Province Postal Code

Employment Start Date To Date

Employment and Educational History

Provide ALL of your employment and educational history for the last 5 years.

Most recent school outside of the United States

Have you attended a foreign school? Financial Support Source

School Name Field of Study Country Street Address Apt / Ste / Flr Number City Province Postal Code From Date To Date

Most recent employment outside of the United States

Have you had foreign employment?

Employer Name Occupation Country Street Address Apt / Ste / Flr Number City Province Postal Code From Date To Date

Birth Information

Date of Birth

City of Birth Province of Birth Country of Birth

Identification Numbers

Social Security Number I do not have a Social Security Number

USCIS Online Account Number

I do not have an Online Account Number

A-Number I do not have an A-Number

Have you ever had a different A-Number?

Other A-Numbers

Immigration Information

Current immigration status, arrival information, passport information, and case details.

Current Status

Country of Citizenship Country of Domicile Current Nonimmigrant Status Current Admit Until Date I-130 Receipt Number I-130 Priority Date Have you previously filed Form I-765? Relationship to Petitioner

Current Passport Information

Passport Number Expiration Date Country of Issuance

Arrival Information

Date of Last Arrival City of Arrival State of Arrival I-94 Record Number Status on I-94 Admit Until Date

Name on I-94

First Name Middle Name Last Name

I-94 Passport Information

Passport Number Expiration Date Country of Issuance

Visa Information

Visa Number Visa Issue Date

N-Number

N-Number I do not have an N Number

Marital Status

Beneficiary Marital Status How many times has beneficiary been married?

Current Spouse

Current Spouse First Name Current Spouse Middle Name Current Spouse Last Name

Date of Birth Country of Birth

A-Number Does not have an A-Number

Current Address

Country

Street Address Apt / Ste / Flr Number City State ZIP Code Province Postal Code

Current Marriage

Date of Marriage Country of Marriage City of Marriage State of Marriage Province of Marriage

Prior Marriages

Father's Information

Legal Name

Father First Name Father Middle Name Father Last Name

Name at Birth

Father First Name Father Middle Name Father Last Name

Birth and Residence Information

Father Date of Birth

Father City of Birth Father Country of Birth Father is deceased

Father City of Residence Father Country of Residence

Mother's Information

Legal Name

Mother First Name Mother Middle Name Mother Last Name

Name at Birth

Mother First Name Mother Middle Name Mother Last Name

Birth and Residence Information

Mother Date of Birth

Mother City of Birth Mother Country of Birth Mother is deceased

Mother City of Residence Mother Country of Residence

Children

Children of the beneficiary, if applicable.

Do you have any children? How many children do you have?

Immigration / Criminal History

Have you ever been to the U.S.? Is your last arrival the first time you visited the U.S.? Have you ever been denied a visa to the U.S.? Have you ever overstayed a U.S. visa? Dates of Overstay Have you ever been a member of the Communist Party? Have you ever had a J-1 visa? Have you ever worked in the U.S. without work authorization? Have you ever been arrested anywhere in the world? How many times? Where were you arrested? Why were you arrested?

Public Charge

Size of Household Annual Household Income Total Value of Household Assets Total Value of Household Liabilities Highest Degree of Education Completed List your certifications, licenses, skills obtained through work experience, and education certificates Have you ever received SSI, TANF, or General Assistance?

Have you ever received long-term institutionalization at government expense?

For Attorney/Paralegal

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