Deferred Action for Certain Young Immigrants Beneficiary’s Questionnaire

1. GENERAL QUALIFICATIONS

–    Did you enter the US on or before June 15th, 2007?       □ Yes □ No

1. Date entered:                                
2. Place (city/state) of entry:                              
3. Age at entry:                                

–       Are you currently enrolled in school ORhave you earned a high school diploma or GED?  □ Yes □ No

1. Name/Address of School                                                                   
2. Year graduated/Date last attended

–       Have you ever been convicted of a felony or two or more misdemeanors? □ Yes □ No

 

1. PERSONAL INFORMATION

 

1. Complete name:                                                                                                                                                                  
2. Other Names Used (include maiden):                                                                                                              
3. Address:                                                                                                                                                                                    
4. Home phone:                                                                                                                                                                                    
5. Cell Phone: Email Address:                                               
6. Are you currently or have you ever been in removal proceedings: □ Yes □ No
7. If so, when:                                                              
8. Where:                                                                                                                      
9. What was the final outcome:                                                        
10. Alien Registration Number (if any):                                                                                                        
11. Social Security Number:                                                                                                                                                  
12. Age: Date of Birth:                                   Marital Status:                                             
13. Height: Weight:            Eye Color:                     Hair Color:                           
14. Date/Place of First Entry into the US:                                                                                                                                            

Date                                                      Place

12. Status at entry:                                                                      
13. Date/Place of Last Entry into the US:                                                                                                                                             

Date                                                   Place

14. Status at entry:                                           
15. Were you a member of the U.S. Armed Forces or Coast Guard? □ Yes □ No
16. List ALL of your addresses in the United States since your date of entry: Use additional paper if needed!
17. Address:                                                                                                                                                                                           

Dates (mm/yy)  of residency at this address:                                                                                               

Address:                                                                                                                                                                                           

Dates  (mm/yy) of residency at this address:                                                                                               

Address:                                                                                                                                                                                           

 

Dates (mm/yy) of residency at this address:                                                                                                

Address:                                                                                                                                                                                           

 

Dates (mm/yy) of residency at this address:                                                                                                

Address:                                                                                                                                                                                           

Dates (mm/yy) of residency at this address:                                                                                                

17. Have you ever departed the United States at any time after June 15, 2007? □ Yes □ No
18. Have you ever been arrested, detained, charged or convicted of any crime, including traffic violations? □ Yes  □ No      If yes, when/where/what/disposition                                                                                                                                                
19. What country issued your last passport?                                                                     
20. What is your current passport number and when does it expire?                                 
21. What is your current annual income amount?                                                        
22. What is the amount of your annual expenses?