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QUESTIONNAIRE:

Upon approval of your Immigrant Visa petition, you and your immediate family members, depending on immigrant visa availability will be eligible to apply for adjustment of status to permanent resident with the Immigration and Naturalization Service. In anticipation of this process, the following information is required to complete the necessary applications.

Last name:          First name:         Middle:
List all other names used:
Home Address:
Home telephone #:         Home fax #:
Office Address, including M/S#:
Office telephone #:         Office fax #:
Title of your position:
H. R. Contact:
H.R. Telephone #
& e-mail:
Date of Birth:              Place of Birth:
     (mo/day/yr)                                                                                  (City, State, Country)
Social Security #:              Nationality:
A# (if any):              Male/Female:
Current Non-immigrant status:              Expires on:
Have you ever before applied for permanent residence status? If so, give date and place of filing
     and final disposition:



1.    Information about your father:
     Last name
     First name
     Date, city and country of birth
     City and country of residence

2.    Information about your mother:
     Maiden name
     First name
     Date, city and country of birth
     City and country of residence

3.    Your residence for the last five years. List present address first.
     Street and Number    City    State    Country    From
(mo./yr)    To
(mo./yr)

Last residence outside the U.S. for more than one year.
     Street and Number    City    State    Country    From
(mo./yr)    To
(mo./yr)

5.
Employment for the last five years. List present employment first.
     Name of Employer, Street and Number    City    State    Country    Occupation    From
(mo./yr)    To
(mo./yr)






6.    Last occupation abroad if not shown above.
     Name of Employer, Street and Number    City    State    Country    Occupation    From
(mo./yr)    To
(mo./yr)


7.    Date of last arrival:

8.    No. on I-94 card:

9.    Place of last entry in the U.S.:

10.    City and country where visa was issued:

11.    8 Digit Non-immigrant visa #:     ________________________________________________________________
          Date Visa was issued:    _______________________________________________________________________
          Visa Expiration Date:    _______________________________________________________________________

12.
Have you ever been in the U.S. on an F-1 student visa?:
          If yes, please list the dates you were in U.S. under F-1 visa status:

13.    Have you ever before applied for employment authorization from CIS?
     If yes, which CIS office?
     Date(s) of application:
     Granted or denied?
     Please provide copies, front and back, of your work authorization card.

14.    Information about your spouse:
     Last name (for wife, give maiden name)
     First name
     Date and place of marriage
     Applying with you?
     Current Status?

15.
Your former husbands or wives (if none, so state)
     Last name (for wife, give maiden name)
     First name
     Date of birth
     City and country of birth
     Date and place of marriage
     Date and place of termination of marriage

16.    List all of your children:    Child #1    Child #2    Child #3
     Last name
     First name
     Middle name
     Male or Female?
     Date of birth
     Place of birth
     Country of Citizenship
     A# (if any)
     Social Security # or T.I.N.:
     Applying with you?

17.    List your present or past membership in or affiliation with every political association, fund foundation, party, club, society, or similar group in the United States or in any other place since your 16th birthday. Include any military service in the past. If none, write “none.” Include the name of the organization, location, dates of membership from and to, and the nature of the organization . If additional space is needed, use separate paper.






QUESTIONS PERTAINING TO TAX ISSUES

Are you self-employed? Mark yes if you own and actively operate a business in which you share in the profits other than as an investor?
     Yes    No
Have you been in the United States for 183 days or more during any one of the three calendar years immediately preceding the current calendar year? Mark “yes” if you received income paid by individuals or institutions located in the United States. Income includes, but is not limited to, compensation for services provided by you, interest, dividends, rents, and royalties.
     Yes    No
Did you file a United States Individual Income Tax Return (Form 1040, 1040A, 1040EZ, or 1040NR) in any of the last three years? If so for which tax year was the last return filed?
     Yes    No
Tax year

18.    Annual income:    $
     Deposits in saving banks in the United States:    $
     Value of personal property:    $
     Market value of stocks and bonds:    $
     Life insurance in the sum of:    $
     With cash surrender value of:    $
     Value of any real estate you own:    $
          With mortgage or other encumbrances thereon amounting to:
$
     Address of such real estate:


19.    List all persons who depend upon you for support wholly or partially.
     Name of person:
     Wholly or partially dependent?
     Age:
     Relationship to you:

20.    List all the persons for whom you have submitted affidavit(s) of support . If none, state “None.”




21.    List all the persons for whom you have ever personally sponsored for an immigrant visa.




COMPLETE ONLY IF THERE IS THE POSSIBILITY OF INTERNATIONAL TRAVEL OVER THE NEXT SIX MONTHS.

22.    Date of intended departure:
23.    Expected length of trip:
24.    Purpose of trip:

THE FOLLOWING QUESTIONS WILL APPEAR ON THE ADJUSTMENT OF STATUS APPLICATION. PLEASE CHECK YES OR NO.

1.    Have you ever, in or outside the U.S:

a)    knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?
     Yes     No
b)    been arrested, cited, charged, indicted, fined or imprisoned for breaking or violation any law or ordinance, excluding traffic violations?
     Yes     No
c)    been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
     Yes     No
d)    exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.?
     Yes    No
2.    Have you received public assistance in the U.S. from any source, including the U.S. government or any state, country, city, or municipality (other than emergency medical treatment), or are you likely to receive public assistance in the future?
     Yes    No
3.    Have you ever:

a)    Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future?
     Yes    No

b)    Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?
     Yes
     No
c)    Knowingly encouraged, induced, assisted, or aided any alien to try to enter the U.S. illegally?
     Yes    No
d)    Illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substances?
     Yes    No
5.    Do you intend to engage in the U.S. in:

a)    Espionage?
     Yes    No
b)    any activity of purpose of which is opposition to. or the control or overthrow of, the Government of the United States, by force, violence or other unlawful means?
     Yes    No
c)    any activity to violate or evade any law prohibiting the export from the United States of goods, technology or sensitive information?
     Yes    No
6.    Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?
     Yes    No

7.
Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist or otherwise participate in the persecution of any person because of race, religion, national origin or political opinion?

Yes
No
8.
Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of
any person because of race, religion, nationality, ethnic origin, or political opinion?
     Yes    No

9.    Have you ever been deported from the U.S. or removed from the U.S. at government expense, excluded within the past year, or are now in exclusion or deportation proceedings?
     Yes    No
10.    Are you under a final order of civil penalty for violating section 274C of the immigration act for use of fraudulent documents, or have you, by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the U.S. or any other immigration benefit?
     Yes    No
11.    Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?
     Yes    No

12.
Have you ever been a J nonimmigrant exchange visitor who was subject to the 2 year foreign residence requirement and not yet complied with that requirement or obtained a waiver?

Yes
No
13.    Are you now withholding custody of a U.S. Citizen child outside the U.S. from a person granted custody of the child?
     Yes    No
14.    Do you plan to practice polygamy in the U.S.?
     Yes
     No

PLEASE SUBMIT THE FOLLOWING DOCUMENTS WITH THE QUESTIONNAIRE:

COMPLETE COPY OF PASSPORT (ALL FAMILY MEMBERS)
COPIES OF ALL FORMS I-797s, I-20s, IAP-66s, EAD cards (ALL FAMILY MEMBERS)
COPY OF I-94 CARD (ALL FAMILY MEMBERS)
COPY OF BIRTH CERTIFICATE, WITH TRANSLATION (IF APPLICABLE). This must be the "long form,” with names of BOTH parents of each applicant. Please provide “long form” which includes your name and both parent’s names. (ALL FAMILY MEMBERS)
COPY OF MARRIAGE CERTIFICATE & DIVORCE DECREE, WITH TRANSLATION (IF APPLICABLE)
COPIES OF U.S. TAX RETURNS FOR PAST 3 YEARS, or YEARS YOU HAVE BEEN IN THE U.S., WHICHEVER IS LESS
LETTER FROM YOUR BANK VERIFYING YOU HAVE A CHECKING AND/OR SAVINGS ACCOUNT, WHEN THE ACCOUNT WAS OPENED AND THAT YOUR ACCOUNT IS IN GOOD STANDING

IF YOU ARE MARRIED, THE FOLLOWING QUESTIONS ARE TO BE ANSWERED BY YOUR SPOUSE:

Last name:          First name:         Middle:
List all other names used:
Home Address:
Home telephone #:         Home fax #:
Date of Birth:              Place of Birth:
     (month/day/year)                                                                     (City, State, Country)
Social Security #:              Nationality:
A# (if any):              Male/Female:
Current Non-immigrant status:              Expires on:
Have you ever before applied for permanent residence status? If so, give date and place of filing
     and final disposition:



25.    Information about your father:
     Last name
     First name
     Date, city and country of birth
     City and country of residence

26.    Information about your mother:
     Maiden name
     First name
     Date, city and country of birth
     City and country of residence

27.    Your residence for the last five years. List present address first.
     Street and Number    City    State    Country    From
(mo./yr)    To
(mo./yr)






28.    Last residence outside the U.S. for more than one year.
     Street and Number    City    State    Country    From
(mo./yr)    To
(mo./yr)


29.    Your employment for the last five years. List present employment first.   (If none, please say “None”)
     Name of Employer, Street and Number    City    State    Country    Occupation    From
(mo./yr)    To
(mo./yr)






30.    Last occupation abroad if not shown above. (If none, please say “None”)
     Name of Employer, Street and Number    City    State    Country    Occupation    From
(mo./yr)    To
(mo./yr)

31.    Date of last arrival:


32.    No. on I-94 card:

33.    Place of last entry in the U.S.:

34.    City and country where visa was issued:

35.    8 Digit Non-immigrant visa #:    ¬¬¬¬¬
     Date Visa was issued:
     Visa Expiration Date:

36.    Have they ever been in the U.S. on an F-1 student visa?:
          If yes, please list the dates you were in U.S. under F-1 visa status:




37.    Have they ever before applied for employment authorization from CIS?
     If yes, which CIS office?
     Date(s) of application:
     Granted or denied?
     Please provide copies, front and back, of your work authorization card.


38.    If applicable, former husbands/ wives (if none, so state)
     Last name (for wife, give maiden name)
     First name
     Date of birth
     City and country of birth
     Date and place of marriage
     Date and place of termination of marriage

39.    List your present or past membership in or affiliation with every political association, fund foundation, party, club, society, or similar group in the United States or in any other place since your 16th birthday. Include any military service in the past. If none, write “none.” Include the name of the organization, location, dates of membership from and to, and the nature of the organization . If additional space is needed, use separate paper.






40.    Did you file a U.S. Individual Income Tax Return in any of the last three years (even if joint)?
     If yes, for which tax year was the last return filed?

41.    If spouse is employed, their annual income:    $

COMPLETE ONLY IF THERE IS THE POSSIBILITY OF INTERNATIONAL TRAVEL OVER THE NEXT SIX MONTHS.
42.    Date of intended departure:
43.    Expected length of trip:
44.    Purpose of trip:

THE FOLLOWING QUESTIONS WILL APPEAR ON THE ADJUSTMENT OF STATUS APPLICATION. PLEASE CHECK YES OR NO .

1.    Have you ever, in or outside the U.S:

a)    knowingly committed any crime of moral turpitude or a drug-related offense for which they have not been arrested?
     Yes     No
b)    been arrested, cited, charged, indicted, fined or imprisoned for breaking or violation any law or ordinance, excluding traffic violations?
     Yes     No
c)    been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?
     Yes     No
d)    exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.?
     Yes    No
2.    Have you received public assistance in the U.S. from any source, including the U.S. government or any state, country, city, or municipality (other than emergency medical treatment), or are they likely to receive public assistance in the future?
     Yes    No
3.    Have you ever:

a)    Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future?
     Yes    No

b)    Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?
     Yes
     No
c)    Knowingly encouraged, induced, assisted, or aided any alien to try to enter the U.S. illegally?
     Yes    No
d)    Illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substances?
     Yes    No
4.    Have you ever engaged in, conspired to engaging, or do they intend to engage in, or have they ever solicited membership or funds for, or have they through any means ever assisted or provided any type of material support to, any person or organization that has been engaged or conspired to engage, in sabotage, kidnapping, political assassination, hijacking, or any other form of terrorist activity
     Yes    No
5.    Do you intend to engage in the U.S. in:

a)    Espionage?
     Yes    No
b)    any activity of purpose of which is opposition to. or the control or overthrow of, the Government of the United States, by force, violence or other unlawful means?
     Yes    No
c)    any activity to violate or evade any law prohibiting the export from the United States of goods, technology or sensitive information?
     Yes    No
6.    Have they ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?
     Yes    No
7.    Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist or otherwise participate in the persecution of any person because of race, religion, national origin or political opinion?
     Yes    No
8.
Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of
any person because of race, religion, nationality, ethnic origin, or political opinion?
     Yes    No

9.    Have you ever been deported from the U.S. or removed from the U.S. at government expense, excluded within the past year, or are now in exclusion or deportation proceedings?
     Yes    No
10.    Are you under a final order of civil penalty for violating section 274C of the immigration act for use of fraudulent documents, or have they, by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the U.S. or any other immigration benefit?
     Yes    No
11.    Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?
     Yes    No
12.    Have you ever been a J nonimmigrant exchange visitor who was subject to the 2 year foreign residence requirement and not yet complied with that requirement or obtained a waiver?
     Yes    No
13.    Are you now withholding custody of a U.S. Citizen child outside the U.S. from a person granted custody of the child?
     Yes    No
14.    Do you plan to practice polygamy in the U.S.?
     Yes
     No

If you would like further information about specific case scenarios or situations, please call our office or email us at ckuck@immigration.net to speak to one of experienced immigration attorneys.

DISCLAIMER: The confidential information provided in this memorandum is for information purposes only and is not intended to be legal advice. This information is not intended to create an attorney-client or other relationship between Kuck Immigration Partners LLC and the recipient. The reader should consult with an immigration attorney before acting in reliance on any such information.

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