Intake Form

Your Name: (LAST, FIRST):

Today’s Date:

Your Relation to Client: (LAST, FIRST):

Your Contact Phone Number:

Your Email Address:

Client Information(Client = person who has an immigration problem because of a criminal case)

Client’s Name (LAST, FIRST):

Who referred you to our office:

Client’s Contact Phone Number:

Client’s Email Address:

Client’s Address:

Client’s A#:

What language(s) does the Client speak?:

Client’s Occupation:

Client’s Current Employer:

Client’s Current Criminal and Immigration Situation

You are currently:Not in CustodyIn Criminal Custody?In Immigration Custody?

If you are currently in criminal custody, what is the scheduled release date?:

Are you currently in deportation or removal proceedings?:NoYes

Briefly describe the immigration problem you are having:

Do you currently have an immigration attorney?:NoYes

Do you have a criminal defense attorney/public defender?:NoYes

Date of Birth:

Country of Citizenship:

Date of First Entry into the U.S:

With what documents did you first enter the U.S., if any?:

What is your current immigration status? (Please select one of the following):UndocumentedWork Permit* HolderVisa Holder

Legal Permanent Resident:Yes

Date LPR granted:

Did you receive your permanent residence through a family member?:NoYes

On what date did the petitioning family member receive permanent resident status?:

Other immigration status:Yes

Are you married?:NoYes

Do you have any children?:NoYes

Do you have any other immediate relatives in the U.S.?:NoYes

Is/was your mother a United States Citizen?:NoYes

Is/was your father a United States Citizen?:NoYes

Does the client own or is the client in the process of buying a home or business in the U.S.?:NoYes

Date(s) you appeared in Immigration Court (if applicable):

Reason you appeared in Immigration Court:

Date you were ordered deported by Immigration Judge (if applicable):

Date you were actually deported to another country (if applicable):

Did you return to the United States after being deported?:NoYes

Date you received a Waiver of Deportability (212(c))* or Cancellation of Removal* or Suspension of Deportation* (if applicable):

List the date of departure, date of return, and purpose of each trip exceeding 90 days out of the U.S. since your first entry:

(Date of Departure):

(Date of Return):

(Purpose of Trip):

Criminal History Summary
FIRST CONVICTION* (If you have more than one conviction, start with the oldest and end with the most recent.)

Date Offense* Committed:

City, State, County of Arrest:*

Please give a brief description of the events that led to your arrest, and list all charges* brought against you:

What court did you appear in?Municipal CourtSuperior CourtFederal CourtOther Court

Date of Plea* / Verdict:

Please list all the charges of which you were convicted. Include the Penal Code Section or Statute* for each:
(Name of Offense) Statute* (Code Number) EXAMPLE: Disorderly Conduct 2C:33-2a

Count 1:

Count 2:

Count 3:

Count 4:

Count 5:

Date of Sentence*:

Length of Jail Sentence:

Date of Release from Custody:

Length of probation or parole?:

Did you appeal* your conviction?:NoYes

Did you complete probation or parole without a violation?:NoYes

SECOND CONVICTION*

Date Offense* Committed:

City, State, County of Arrest:

Please give a brief description of the events that led to your arrest, and list all charges* brought against you:

What court did you appear in?:Municipal CourtSuperior CourtFederal CourtOther Court

Date of Plea* / Verdict:

Please list all the charges of which you were convicted. Include the NJSA Code Section or Statute* for each:
(Name of Offense) Statute* (Code Number) EXAMPLE: Disorderly Conduct 2C:33-2a

Count 1:

Count 2:

Count 3:

Count 4:

Count 5:

Date of Sentence:

Length of Jail Sentence:

Date of Release from Custody:

Length of probation or parole?:

Did you appeal* your conviction?:NoYes

Did you complete probation or parole without a violation?:NoYes

THIRD CONVICTION*

Date Offense* Committed:

City, State, County of Arrest:

Please give a brief description of the events that led to your arrest, and list all charges* brought against you:

What court did you appear in?:Municipal CourtSuperior CourtFederal CourtOther Court

Date of Plea* / Verdict:

Please list all the charges of which you were convicted. Include the Penal Code Section or Statute* for each:
(Name of Offense) Statute* (Code Number) EXAMPLE: Disorderly Conduct 2C:33-2a

Count 1:

Count 2:

Count 3:

Count 4:

Count 5:

Date of Sentence:

Length of Jail Sentence:

Date of Release from Custody:

Length of probation or parole?:

Did you appeal* your conviction?:NoYes

Did you complete probation or parole without a violation?:NoYes

Please leave this field empty.

Please enter an answer in digits:

four + eight =

Intake Information Sheet

Thank you for your interest in our services.

Please provide information so we can evaluate your situation, and see whether we can help.

If you do not understand certain words or questions, look at the glossary on the last page of this form. All words marked with an * are defined in the glossary. If you still need help, contact our office at (201) 703-9400.

If you do not remember your criminal history information, or need help getting the documents listed below, for a fee we can help you get the necessary information.

If you need more space to answer a question completely, please use a separate page.

Please make additional copies of the Conviction Information Sheet (Page # 4), if necessary, to include information on every one of your criminal cases.

We will not release any information you provide to anyone without your permission.

For EACH criminal case, please send copies of the following documents, if available:

The charging paper (i.e., complaint, information, etc.)
The police report
The state and/or FBI rap sheet or criminal history report
If you have already been convicted or have pleaded guilty or no contest, please also send:
The docket or clerk’s minutes from the plea and sentence
The reporter’s transcript of the plea and sentence
Any waiver of rights form signed by the defendant, and
The probation report

Once you have completed the Intake Form, submit it to us over the internet, fax it to us at (201) 703-9430, or mail it to us at: 0-100 27th Street, Fair Lawn, NJ 07410.

Consultation: We will review the form without charge. If we recommend a consultation, we will contact you to schedule an appointment. A consultation in person at our office or by telephone is up to 1½ hours, as necessary. We cannot conduct a consultation without an appointment.

For further information on our office, the services we offer, the immigration consequences of criminal cases, and how to clear NJ convictions from your records, visit our website: www.njcrimmigration.com

Intake Form

Client Information(Client = person who has an immigration problem because of a criminal case)

Client’s Current Criminal and Immigration Situation

Criminal History Summary FIRST CONVICTION* (If you have more than one conviction, start with the oldest and end with the most recent.)

SECOND CONVICTION*

THIRD CONVICTION*

Intake Information Sheet

Accused of a Crime & Facing Immigration Issues?

Accused of a Crime & Facing Immigration Issues?

Overcome Immigration Problems Legally

Overcome Immigration Problems Legally

Don't Get Burned By Immigrant Clients

Criminal History Summary
FIRST CONVICTION* (If you have more than one conviction, start with the oldest and end with the most recent.)