Intake Sheet Online | Scott and Associates

Alien's information

1. Alien's Family Name(s): *

Given Name: *

Date of Birth: *

Petitioners's information

2. Petitioner's Family Name(s): *

Given Name: *

Date of Birth: *

Petitioner is a: *

US Citizen

Lawful permanent resident

Other (enter description)

Other description:

Contact information

3. email (list ONE): *

phone (for leaving messages): *

US mailing address: *

Citizenship

4. Alien's countries of citizenship and permanent residence (list all): *

5. Petitioner's countries of citizenship and permanent residence (list all): *

Date and Signature

I attest (a) that the above is true to the best of my knowledge, (b) that the alien has not entered or exited the country except as listed on #9 of this form, (c) that the alien has not been arrested except as listed on #12 this form, (d) that if I discover that the alien has entries or exits not listed above or arrests not listed above, that I will immediately inform the attorneys in writing, and (e) that by entering my name and date below I am signing this document.

Name of person completing the Intake Sheet: *

Signature date: *