移民客户信息采集表起草

新移民客户信息采集表（李一）
仅供律师事务所内部初审与冲突审查之用。提交本表并不构成或建立律师-客户关系。任何法律意见仅在签署正式委托协议并完成利益冲突审查后提供。本表收集信息可能涉及不同司法辖区之移民与国籍法律；具体法律适用以拟定居/申请之接收国法律为准。

一、基本身份信息
1. 客户姓名（与护照一致）：李一
2. 曾用名/别名（含英文及母语拼写，若无填“无”）：
3. 性别：
4. 出生日期（YYYY-MM-DD）：
5. 出生地（城市/省/国家）：
6. 国籍/公民身份（可多选）：
7. 民族/部族（如接收国要求填写）：
8. 婚姻状况（未婚/已婚/同居伴侣/离婚/丧偶/分居）：
9. 国家身份证号码（如有）：
10. 护照号码、签发国、签发日、到期日：
11. 其他旅行证件（如难民旅行证、通行证）：
12. 政府移民档案号（如有：A-Number/UID/Client ID/IRCC/UCI等）：
13. 税号/社会保障号（如有）：

二、联系信息与沟通授权
1. 现居住地址（含邮编与国家）：
2. 邮寄地址（如不同）：
3. 联系电话（可接收短信：是/否；时区）：
4. 电子邮箱（用于接收时限与机密通讯：是/否）：
5. 首选语言；是否需要宣誓或专业口译：是/否。口译语言：
6. 同意使用加密电子方式传送文件与身份信息：是/否
7. 紧急联系人姓名、关系、电话、电子邮箱：

三、移民目标与拟办理事项
1. 主要目标（例：临时入境签证/学习许可/工作许可/家庭团聚/技术移民/投资移民/庇护或难民保护/国籍入籍/身份维持或更改/驱逐抗辩/豁免/复核与上诉）：
2. 期望时间表与关键时限（如身份到期日、递交截止、听证日期）：
3. 优先考虑因素（家庭团聚、工作安排、旅行限制、合规风险控制等）：

四、当前移民身份与在境内状况（如适用）
1. 当前所在地（境内/境外）：
2. 当前身份类别与文件编号（签证/居留许可/I-94/电子入境记录/BRP等）：
3. 入境口岸、入境日期、获准停留期限：
4. 是否存在逾期停留、未经许可工作或违反身份条件：是/否。若是，说明起止日期与情节：
5. 是否持有有效回避递解/暂缓递解（DACA/TPD/配套人道身份等同类救济）：是/否

五、入出境与旅行史（一般填报近10年，或自首次申请起）
1. 近10年所有入境与离境记录（日期/国家/停留目的/停留时长）：
2. 曾否因签证或入境被拒、被二次检查、撤销入境或即刻遣返：是/否。若是，说明日期、地点、文书编号及理由：
3. 是否触发不予准入事由（inadmissibility）或居留不合规风险（例如虚假陈述、体检不合格、刑事定罪、国家安全、公共负担、先前递解或非法入境等）：是/否。若是，详述：

六、以往移民申请与程序经历
1. 历次递交的签证/许可/身份/庇护/难民/国籍/绿卡等申请（受理机关、类别、递交与裁决日期、结果、受理号码）：
2. 是否曾撤回、被拒、被驳回、被视为放弃或被认定欺诈/虚假陈述：是/否。若是，提供决定书复印件：
3. 是否有未决申请、补件通知、体检或生物信息采集通知：是/否。详述期限：
4. 是否曾申请或获准任何豁免（如禁止入境事由豁免、逾期/非法入境豁免等同类救济）：是/否。详述：

七、驱逐/递解/执法与司法程序（如适用）
1. 是否曾收到开庭传票/开案通知（如NTA/等值文书）：是/否。开案编号、法庭地点、下一步日期：
2. 曾否被签发递解令/自愿离境令/排除令/遣返令：是/否。附决定书与执行情况：
3. 是否有保释、移民拘押、替代羁押或监管报道要求：是/否：
4. 行政复议、司法复核或上诉经历（机构/法院、案号、结果、在途事项）：

八、刑事、安保与合规披露
1. 曾否被逮捕、起诉、缓起诉、定罪、缓刑、和解、清封/撤销记录：是/否。逐项列明罪名（原文）、法域、法条、判决日期与结果，并附官方记录：
2. 涉及家庭暴力、毒品、酒驾、欺诈、洗钱、武器、人口贩运或道德败坏类犯罪：是/否。详述：
3. 曾否参与武装组织、强制服役、情报/安全部门、民兵或政治暴力：是/否。详述服务性质、期限与职责：
4. 是否曾作虚假陈述、使用伪造文件或他人身份以获取签证/入境/就业/福利：是/否：
5. 是否存在未缴税款、虚报税、社会福利不当领取、移民体检不合格或疫苗不全：是/否。详述并提供补救凭证：

九、健康、福利与公共负担审查（依接收国法可能影响可受理性）
1. 重大疾病、慢性病、精神健康诊断、传染病史（按医嘱披露）：
2. 疫苗接种记录是否完整：是/否。不全项目：
3. 近3年是否领取需经济状况评估的政府福利：是/否。项目、金额、期间：
4. 经济担保人/担保书（如I-864等同类文件）可用性：有/无。担保人姓名与收入证明概况：

十、家庭关系与担保人信息
1. 现任配偶/同居伴侣信息（姓名、生日、国籍、婚姻登记日期/地点、其移民身份）：
2. 以往婚姻/伴侣关系（姓名、婚期、解除日期、方式、子女抚养安排）：
3. 子女信息（亲生/继子女/收养；姓名、生日、国籍、在何国居住、是否拟作随行或派生受益人）：
4. 双亲信息（姓名、生日、国籍、是否公民/永久居民、是否提供担保）：
5. 直系/旁系亲属中是否有接收国公民或永久居民：是/否。关系与身份证明：

十一、教育与职业资格
1. 学历（最高学历起，学校、专业、学位、起止日期）：
2. 职业资格/执照（名称、发证机构、有效期）：
3. 外语能力与标准化考试（IELTS/TOEFL/TCF/职业英语等）：
4. 现雇主/拟雇主信息（名称、地址、职位、职责、年薪、是否有雇主担保/LMIA/岗位批准等同类文件）：
5. 过去10年工作经历（雇主、职位、起止日期、是否全职/兼职）：

十二、保护类与人道项目（如适用）
1. 是否担心基于种族、宗教、国籍、特定社会群体或政治见解之迫害或严重伤害：是/否。简述事实、关键时间线、施害者与国家保护是否可得：
2. 是否涉及家庭暴力、人口贩运、强迫劳动、童年虐待或无监护未成年人情形：是/否。支持文件概况：
3. 是否存在返国不可行或过度困难之人道理由：是/否。说明：

十三、财务与资产情况（用于可受理性与担保评估）
1. 年收入、主要资产、存款、负债：
2. 税务申报遵从情况（近3年报税/缴税证明）：
3. 第三方资助或担保安排：

十四、潜在不利因素自查清单
请勾选适用项，并在相应章节详述与附证：
[ ] 逾期停留/未经许可工作/违反停留条件
[ ] 先前签证或移民申请被拒/撤回/撤销
[ ] 刑事记录（含轻罪/治安/酒驾）
[ ] 虚假陈述/伪造或篡改文件/他人身份使用
[ ] 传染病或未完成强制疫苗接种
[ ] 公共负担风险或福利领取
[ ] 既有递解令/离境令/不准入境期限
[ ] 国家安全/恐怖主义/军事或安保相关经历
[ ] 未决诉讼、破产或重大财务纠纷
[ ] 其他可能影响可受理性或可递解性的事项

十五、已持有或可提供的材料清单（请标注“已备/待补/无”）
- 护照、旅行证件、国家身份证
- 出生、婚姻、离婚、收养等民事登记文件（经公证/认证/翻译）
- 近期证件照、体检及疫苗记录
- 过往签证、入境章、电子入境记录、居留卡、许可或批文
- 受理函、补件通知、拒签信、裁决书、上诉决定
- 警局证明、无犯罪记录证明、法院判决与最终处分
- 教育文凭、成绩单、职业资格、执照
- 雇佣合同、工作证明、纳税/社保证明、工资单
- 资金证明、银行对账单、资产证明
- 亲属关系证明、担保书及担保人财税材料
- 人道/保护类证明（医疗/警方/社工/庇护机构文书、宣誓陈述）
- 其他：

十六、利益冲突与相对方识别
1. 与本所现有或既往客户是否存在对立或潜在冲突（如配偶/前配偶/雇主/商业伙伴/中介）：是/否。列明姓名与关系：
2. 其他已聘律师、顾问或中介机构名称与联系方式：

十七、重要期限与提醒
1. 当前身份或签证到期日：
2. 听证、面谈、体检、生物信息采集、补件、上诉期限：
3. 优先日期/名额排期（如适用）：

十八、声明与授权
1. 真实性声明：本人确认本表所载信息完整、真实、准确，并知悉虚假或遗漏可能构成不予准入、可递解或拒签之依据，亦可能导致刑事或行政责任。
2. 隐私与数据处理：本人同意本所为提供法律服务之目的在适用法律允许范围内收集、使用、储存与跨境传输本人个人信息及敏感信息，并采取合理保密与安全措施。本人知悉可按适用法行使查阅、更正与撤回同意之权利。
3. 沟通授权：本人同意通过所提供之联系方式接收与案件相关之法律通讯与时限通知，并了解未及时回复可能影响案件权利主张与时效。
4. 文档核验：本人同意本所于必要时向政府机关依法申请/调取移民档案或信息（如信息公开或档案调取程序），并将另行签署正式授权书。

签字栏
- 客户签名（手写或电子签名）：
- 签署日期（YYYY-MM-DD）：
- 代填/口译人员姓名与签名（如适用）：
- 代填/口译语言与声明：本人已忠实准确传达并记录客户陈述。

提交指引
- 请以清晰扫描件或高质量照片提交材料；非本国语言文件请附经认证译本。
- 请勿递交原件，除非本所书面要求。
- 请在5个工作日内补齐“待补”材料或书面说明原因与预计时间。
- 如有新进展（地址变更、婚姻/就业变动、警方接触、政府来函），请于48小时内书面告知本所。

备注
- 本表为通用移民与国籍法律信息采集工具，具体法律分析将依据目标法域之成文法、行政规章、官方指引与判例/行政先例进行个案适用与风险评估。若任何条目不适用于您的情况，请标注“不适用”。

New Client Immigration Intake Questionnaire (Wang Min)

Purpose and Instructions
- Purpose: This questionnaire is designed to collect complete and accurate information necessary to evaluate immigration options, admissibility, potential bars and waivers, and eligibility for benefits under the Immigration and Nationality Act (INA), corresponding regulations (8 C.F.R.), and applicable guidance.
- Confidentiality: Information provided is confidential and, if an attorney-client relationship is later formed, protected by the attorney-client privilege and attorney work-product doctrine to the extent permitted by law. At the intake stage, no legal services are provided and no attorney-client relationship is formed until a written engagement agreement is executed following a conflict check.
- Accuracy: Provide truthful, complete, and consistent information. Misrepresentations to counsel or to the U.S. Government may have serious consequences, including inadmissibility for fraud or willful misrepresentation (INA § 212(a)(6)(C)(i)).
- Documents: Provide legible copies of all relevant immigration, civil status, criminal, and travel documents referenced herein.

Language and Accessibility
- Preferred language: __________ Interpreter needed: [ ] Yes [ ] No
- If Yes, interpreter name/contact and certification (to be completed at signature page).

Section 1. Conflicts Check and Identifying Information
- Full legal name (as in passport): Wang Min
- Other names/aliases/maiden names/Chinese characters (if any): __________________________________
- Date of birth (YYYY-MM-DD): __________ Place of birth (City/Province/Country): __________
- Country(ies) of citizenship or nationality: __________
- A-Number (if any): A# __________
- U.S. Social Security Number (if any): __________
- USCIS Online Account Number (if any): __________
- Passport number(s) and issuing country(ies): __________ Expiration date(s): __________
- Current U.S. address: __________________________________ County: __________
- Phone(s): __________ Email: __________
- Emergency contact (name/relationship/phone/email): __________
- Prior counsel in any immigration matter (name/firm): __________ Dates: __________
- Adverse parties or related parties for conflicts check (e.g., petitioner, employer, spouse, prior spouse, sponsor): list full legal names and dates of birth:
  1) __________ DOB: __________ Relationship: __________
  2) __________ DOB: __________ Relationship: __________

Section 2. Immigration Status and History
- Current immigration status in the U.S. (e.g., B-2, F-1, H-1B, TPS, DACA, parole, no status): __________
- Last entry to the U.S.: Date: __________ Place: __________ Class of admission (per I-94): __________
- I-94 number: __________ Admit until date or D/S: __________
- Prior entries to the U.S. (list all, most recent first): date/place/class of admission: __________
- Have you ever overstayed or violated status (e.g., unauthorized employment, failure to maintain full-time study)? [ ] Yes [ ] No. If Yes, provide details and dates: __________
- Have you ever departed after accruing unlawful presence of 180+ days or 365+ days (INA § 212(a)(9)(B))? [ ] Yes [ ] No. Details/dates: __________
- Have you ever reentered or attempted to reenter without inspection after prior removal or after >1 year unlawful presence (INA § 212(a)(9)(C))? [ ] Yes [ ] No. Details: __________
- Have you ever been issued a Notice to Appear (NTA), placed in removal, exclusion, or deportation proceedings, or ordered removed/voluntarily departed (INA § 240, § 235(b), § 240B)? [ ] Yes [ ] No. If Yes, EOIR case number (if known): __________ Judge/Location: __________ Outcome/date: __________
- Have you ever been refused admission at a port of entry, withdrawn an application for admission, or been expeditedly removed (INA § 235(b)(1))? [ ] Yes [ ] No. Details: __________
- Have you ever been found inadmissible or deportable or granted any waiver (I-601, I-601A, I-212, § 212(d)(3))? [ ] Yes [ ] No. If Yes, specify ground(s) and decision(s): __________
- J-1/J-2 two-year home residence requirement (INA § 212(e)): [ ] Never J status [ ] Subject [ ] Not subject [ ] Unsure. If subject, any waiver (e.g., No Objection, Persecution, Hardship, IGA): __________

Section 3. Prior Applications and Immigration Documents
List all immigration filings, with approximate dates, locations, and outcomes. Provide copies of receipts, approvals, denials, RFEs, NOIDs, biometrics notices, and decisions.
- Family-based: I-130, I-129F, I-485, I-751, N-400, I-90, I-131 (AP), I-765 (EAD): __________
- Employment-based: PERM, I-140, I-485, I-129, H/L/O/P/E petitions: __________
- Humanitarian: I-589 (asylum), I-730, I-918 (U), I-914 (T), VAWA (I-360), TPS, DACA, SIJ (I-360), humanitarian parole: __________
- Waivers/consular: DS-160/260, § 221(g) refusals, § 212(d)(3) waivers, I-601, I-601A, I-212: __________
- FOIA/records requests (USCIS/CBP/ICE/EOIR/DOS): __________

Section 4. Family and Household
- Current marital status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed [ ] Separated
- Current spouse: Full name: __________ DOB: __________ Country of birth: __________
  - Date and place of marriage: __________ If spouse is a U.S. citizen or LPR: [ ] USC [ ] LPR [ ] Neither
  - Prior marriages for you: number: ___; for spouse: number: ___. Provide details and termination documents for each prior marriage (divorce decree, death certificate, annulment).
- Children (biological, adopted, step), list all: full name, DOB, place of birth, current location, immigration status: __________
- Parents: names, DOBs, country of residence, immigration status if in U.S.: __________
- Household size for affidavit of support/public charge analysis: __________
- Has anyone filed an I-130/I-140/I-360/I-730 on your behalf? [ ] Yes [ ] No. If Yes, petitioner’s name, relationship, receipt number, and priority date: __________
- Have you ever filed any petitions for relatives? [ ] Yes [ ] No. If Yes, list: __________
- Evidence of bona fide marital relationship (if applicable): joint lease/mortgage, joint bank accounts, insurance, taxes, utility bills, photos, correspondence, travel, affidavits.

Section 5. Education, Employment, and Financial Information
- Highest education level, degrees, institutions, dates: __________
- English proficiency: [ ] Fluent [ ] Intermediate [ ] Basic [ ] None. Other languages: __________
- Current and recent employment (last 10 years): employer name, address, job title, start/end dates, full-/part-time, salary, supervisor, EIN (if known): __________
- Prior unauthorized employment or work without proper authorization: [ ] Yes [ ] No. Details: __________
- Self-employment or ownership interests: __________
- Income (most recent tax year): wages, business income, other: __________
- Tax filings: Have you filed U.S. federal/state tax returns for all required years? [ ] Yes [ ] No. If No, explain: __________
- Public benefits received by you or household members (e.g., SSI, TANF, SNAP, Medicaid, housing assistance). Note: Certain benefits may not affect admissibility; provide full details with dates: __________
- Potential sponsor(s) for Form I-864/I-864A (if family-based AOS or IV): names, status, income, household size: __________
- Assets and liabilities (if relevant to public charge or I-864 sufficiency): __________

Section 6. Criminal, Security, and Conduct-Related Matters
Note: All arrests, citations, charges, and convictions must be disclosed, including expunged, sealed, or juvenile matters, as they may still be relevant to immigration (see INA § 212(a)(2) and related case law). Provide certified disposition records.
- Arrests/charges/convictions anywhere in the world: [ ] Yes [ ] No. If Yes, provide date, place, offense, statute, disposition/sentence, immigration consequences: __________
- Controlled substances use/possession, trafficking, or admission to essential elements: [ ] Yes [ ] No. Details: __________
- Prostitution, commercialized vice, money laundering, or human trafficking involvement: [ ] Yes [ ] No. Details: __________
- Immigration fraud/misrepresentation, false claim to U.S. citizenship, sham marriage, document fraud (INA § 212(a)(6)(C) and 18 U.S.C. § 1546): [ ] Yes [ ] No. Details: __________
- Alien smuggling/assisting unlawful entry (INA § 212(a)(6)(E)): [ ] Yes [ ] No. Details: __________
- Security-related grounds (terrorism-related inadmissibility grounds, memberships, training, material support, espionage) (INA § 212(a)(3)): [ ] Yes [ ] No. Details: __________
- Military service (any country), rank, dates, discharge, specialized training: __________
- Memberships/affiliations/organizations, including political parties, student groups, online forums, social media handles used in visa applications (past 5 years): __________
- Domestic violence or restraining orders (note VAWA/U relief may be implicated): [ ] Yes [ ] No. Details: __________

Section 7. Health and Vaccination
- Communicable diseases of public health significance, physical or mental disorders with associated harmful behavior, drug abuse/addiction, or lack of required vaccinations (INA § 212(a)(1)): [ ] Yes [ ] No. If Yes, describe diagnoses, treatment, medications, and documentation: __________
- Vaccination history (MMR, Varicella, Tdap, Influenza, COVID-19, Hepatitis B, etc.). Provide records: __________
- Health insurance coverage in the U.S.: [ ] Yes [ ] No. Carrier/Policy: __________
- Disabilities or accommodations needed for USCIS/EOIR appearances: __________

Section 8. Travel and Identity History
- All passports/national ID numbers, issuing authorities, and validity dates: __________
- Countries of residence for more than 6 months since age 16: __________
- International travel history for last 10 years (approximate dates, countries): __________
- Prior visa applications and outcomes (B/F/J/H/L/O/P/E/K/immigrant): dates, posts, refusals (INA § 214(b), § 221(g), § 212(a) grounds), administrative processing: __________
- Social media identifiers as required in DS-160/260 (last 5 years): __________

Section 9. Fear-Based and Humanitarian Considerations
- Do you fear harm, persecution, or torture if returned to your country? [ ] Yes [ ] No
  - If Yes, describe protected grounds (race, religion, nationality, political opinion, particular social group), incidents, dates, perpetrators, and internal relocation considerations. Note: asylum (INA § 208), withholding (INA § 241(b)(3)), and CAT protection may be implicated: __________
- Victimization and protective relief:
  - VAWA eligibility (spouse/parent/child of abusive USC/LPR): [ ] Yes [ ] No. Details: __________
  - U nonimmigrant status (victim of qualifying crime, helpful to law enforcement): [ ] Yes [ ] No. Law enforcement certification possible? __________
  - T nonimmigrant status (severe trafficking, compliance with requests): [ ] Yes [ ] No. Details: __________
  - SIJ (Special Immigrant Juvenile): [ ] Yes [ ] No. Details: __________
  - TPS or DED eligibility or history: [ ] Yes [ ] No. Details: __________
  - Parole programs (e.g., humanitarian parole, family reunification, CHNV): [ ] Yes [ ] No. Details: __________

Section 10. Case Objectives and Strategy Inputs
- Primary immigration goal(s) (e.g., family-based AOS, consular processing, employment-based IV, naturalization, nonimmigrant change/extension, removal defense): __________
- Preferred processing (AOS in U.S. vs. consular processing abroad): __________
- Time constraints or status expiration dates (provide exact dates): __________
- Potential qualifying relatives for hardship waivers (USC/LPR spouse/parent/fiancé(e)): __________
- Priority date and category (if known) and country of chargeability: __________
- For employment-based options: job offer details, wage, prevailing wage, remote/hybrid/on-site, worksite locations, degree requirements, and whether PERM labor certification is contemplated: __________

Section 11. Document Checklist (provide copies, not originals, unless requested)
- Government IDs: passports (all), national IDs, birth certificate with certified translation, household register (if applicable).
- U.S. immigration: visas, I-94s, approval/denial notices, EADs, I-20/DS-2019, I-797s, entry stamps, travel history (CBP I-94 printout), NTAs, EOIR orders, ICE check-in records.
- Civil documents: marriage certificates, divorce decrees, death certificates, adoption decrees, name change orders.
- Criminal records: police reports, charging documents, certified court dispositions, probation/parole records.
- Financial/tax: last three years tax returns and W-2/1099, pay stubs, bank statements, employment letters, assets evidence.
- Relationship evidence: joint financials, leases/mortgages, insurance, photos, correspondence, affidavits.
- Medical: vaccination records, medical exam results (I-693 if applicable).
- Prior filings: complete copies of all forms submitted to USCIS/EOIR/DOS and all decision notices.
- Other: evidence supporting humanitarian claims, country condition reports, police clearances where required.

Section 12. Communications, Privacy, and Authorizations
- Preferred communication method: [ ] Email [ ] Phone [ ] Secure portal [ ] Messaging (encrypted)
- Consent to receive electronic communications and documents, including confidential information: [ ] Yes [ ] No
- Permission to contact prior counsel to obtain your file: [ ] Yes [ ] No. If Yes, provide authorization and contact details: __________
- Authorization to file FOIA/Privacy Act requests (USCIS/CBP/ICE/EOIR/DOS) to obtain your records: [ ] Yes [ ] No
- Consent to store your data in secure cloud-based systems compliant with applicable privacy and professional responsibility rules: [ ] Yes [ ] No

Section 13. Acknowledgments and Certifications
Please read carefully. Initial each statement.
- I understand that submission of this questionnaire does not create an attorney-client relationship, and no legal advice is provided until a written engagement agreement is executed and any conflicts are cleared. Initial: _____
- I certify that the information provided herein and in attached documents is true, correct, and complete to the best of my knowledge and belief. I understand that providing false information to U.S. immigration authorities can lead to denial, removal, inadmissibility under INA § 212(a)(6)(C), and criminal penalties. Initial: _____
- I authorize the firm to use the information provided solely for conflicts checking and preliminary evaluation of my case. Initial: _____
- I will promptly update the firm if any information changes or if I receive any notices from USCIS, DOS, CBP, ICE, or EOIR. Initial: _____

Signature Blocks
- Client signature: _______________________________ Date: __________
- Printed name: Wang Min

Interpreter Certification (if applicable)
- I, ________________________, certify that I am competent to interpret between English and __________; I have read and interpreted the contents of this questionnaire to the client in the client’s preferred language, and the client confirmed understanding.
- Interpreter signature: __________________________ Date: __________
- Contact information: ____________________________

For Office Use Only (to be completed by firm)
- Date received: __________ File number: __________ Conflict check complete: [ ] Clear [ ] Conflict
- Attorney assigned: __________ Next steps: __________ Critical dates: __________

Notice
- This form is intended for use in evaluating potential eligibility and risks under U.S. immigration law, including admissibility and removability grounds under INA §§ 212 and 237, eligibility for family- and employment-based immigrant and nonimmigrant classifications, humanitarian relief, and available waivers. The firm will apply current statutes, regulations, policy guidance, and controlling case law at the time of formal engagement. Policies are subject to change; final determinations are made by USCIS, DOS, CBP, ICE, and EOIR.

Formulario de Información Inicial del Cliente (Intake) – Inmigración
Cliente: Ana

Propósito y aviso
- Este formulario tiene por objeto recabar información completa y exacta para evaluar su elegibilidad y riesgos conforme a la Ley de Inmigración y Nacionalidad de los Estados Unidos y los reglamentos federales aplicables. La exactitud de los datos es esencial para un análisis jurídico adecuado.
- El envío de este formulario no crea por sí mismo una relación abogado-cliente. Dicha relación surge únicamente mediante acuerdo de representación por escrito debidamente firmado por usted y el despacho.

Instrucciones
- Responda todas las preguntas. Si no aplica, indique “N/A”. Si desconoce un dato, indique “Desconocido” e informe si puede obtenerlo.
- Adjunte copias legibles de los documentos solicitados en la lista de verificación al final.

1) Datos de identificación
- Nombre(s) completos: Ana ______________________
- Apellido(s): ______________________
- Otros nombres/alias/variaciones: ______________________
- Número A (si lo tiene): ______________________
- Número de Seguro Social o ITIN (si aplica): ______________________
- Número de cuenta en línea de USCIS (si aplica): ______________________
- Fecha de nacimiento (día/mes/año): ______________________
- Ciudad y país de nacimiento: ______________________
- Nacionalidad(es) actual(es): ______________________
- Sexo/género (cómo figura en documentos de viaje): ______________________
- Estado civil: [ ] Soltera [ ] Casada [ ] Divorciada [ ] Viuda [ ] Separada legalmente
- Idioma preferido: ______________________ ¿Requiere intérprete? [ ] Sí [ ] No
- Teléfono: ______________________ Correo electrónico: ______________________
- Domicilio actual (calle, ciudad, estado, código postal): ______________________
- Domicilios en los últimos 5 años (con fechas): ______________________

2) Documentos de identidad y viaje
- Pasaporte (país, número, fecha de emisión y vencimiento): ______________________
- Documento de identidad nacional (tipo y número): ______________________
- I‑94 (número, fecha de entrada, clase de admisión): ______________________
- Visa más reciente (categoría, número, fecha de emisión/expiración, consulado emisor): ______________________
- Autorización de ingreso condicional (parole), TPS o DACA (fechas y estatus): ______________________
- J‑1/J‑2: ¿Sujeta a regla de residencia de dos años? [ ] Sí [ ] No [ ] Desconocido. ¿Solicitó/obtuvo exención? ______________________

3) Historial de entradas y salidas (EE. UU. y otros países)
Para cada entrada a EE. UU.:
- Fecha, puerto de entrada, medio (aéreo/terrestre/marítimo): ______________________
- Modalidad: [ ] Admitida con inspección [ ] Parole [ ] Sin inspección [ ] Otra: __________
- Clase de admisión (B‑2, F‑1, etc.): ______________________
Para cada salida de EE. UU. (fecha y destino): ______________________
- Estancias/solicitudes en terceros países (asilo, residencia, visas): ______________________

4) Antecedentes migratorios y procedimientos
- ¿Ha recibido Notificación de Comparecencia (NTA)? [ ] Sí [ ] No. Fecha y tribunal (EOIR): ______________________
- Número de caso (si lo conoce): ______________________
- Resultado: [ ] En curso [ ] Orden de deportación/remoción [ ] Salida voluntaria [ ] Terminación [ ] Otra: __________
- Apelaciones (BIA/Corte Federal): ______________________
- ¿Ha sido detenido por CBP/ICE? [ ] Sí [ ] No. Fechas y lugar: ______________________
- ¿Ha firmado salida expedita o supervisada, reinstalación de orden o retorno voluntario? ______________________
- Solicitudes/peticiones previas (USCIS/Consulado): [ ] I‑130 [ ] I‑140 [ ] I‑485 [ ] I‑589 [ ] I‑765 [ ] I‑131 [ ] I‑212 [ ] I‑601 [ ] I‑601A [ ] I‑730 [ ] N‑400 [ ] TPS [ ] DACA [ ] U [ ] T [ ] VAWA [ ] SIJS [ ] Otras: __________
  - Números de recibo, estatus y decisiones (aprobada/denegada/pedidos de pruebas): ______________________

5) Datos familiares y peticionarios potenciales
- Cónyuge actual (nombre completo, fecha y lugar de nacimiento, estatus migratorio): ______________________
- Fecha y lugar de matrimonio: ______________________ ¿Convive actualmente? [ ] Sí [ ] No
- Matrimonios anteriores (suyos y del cónyuge) con fechas de inicio/fin: ______________________
- Hijos (nombres, fechas y lugares de nacimiento, estatus migratorio): ______________________
- Padres (nombres completos, estatus): ______________________
- Hermanos (nombres y estatus): ______________________
- Posibles peticionarios (ciudadano/residente permanente/empleador): ______________________

6) Educación y empleo
- Nivel educativo más alto, títulos y fechas: ______________________
- Empleador actual (nombre, dirección, cargo, fechas, salario): ______________________
- Empleadores previos últimos 5 años: ______________________
- ¿Ha trabajado sin autorización? [ ] Sí [ ] No [ ] Desconocido
- ¿Ha presentado impuestos en EE. UU.? [ ] Sí [ ] No. Años: __________ ¿Con ITIN/SSN? __________

7) Historial penal, de seguridad y cumplimiento
Marque todo lo que aplique e indique fechas, lugares y resultado (arresto, cargos, condena, desestimación, programa de desvío, limpieza de antecedentes):
- [ ] Arrestos/cargos/convicciones en cualquier país
- [ ] Órdenes de protección o violencia doméstica
- [ ] Conducción bajo influencia (DUI/DWI)
- [ ] Posesión/consumo problemático de sustancias
- [ ] Afiliación a organizaciones o milicias; entrenamiento o actividad paramilitar
- [ ] Declaración falsa de ciudadanía estadounidense o voto en elecciones de EE. UU.
- [ ] Fraude/mala representación a autoridades migratorias o consulares
- [ ] Contrabando de personas/ayuda a entrada irregular
- [ ] Incumplimiento de manutención de hijos/orden judicial
- [ ] Multas o infracciones significativas
Explique con detalle y adjunte documentos judiciales/policíacos: ______________________

8) Salud y consideraciones médicas
- Condiciones médicas relevantes, tratamientos, hospitalizaciones: ______________________
- Vacunación (si conoce su cartilla): ______________________
- Discapacidad o impedimento para exámenes/entrevistas o aprendizaje del inglés/cívica (posible N‑648): ______________________
- Embarazo: ______________________

9) Recursos financieros y patrocinio
- Ingresos anuales del hogar: ______________________
- Tamaño del hogar (para fines de patrocinio): ______________________
- Bienes y deudas principales: ______________________
- Declaraciones de impuestos (últimos 3 años) adjuntas: [ ] Sí [ ] No
- Posible patrocinador financiero (I‑864/I‑134): nombre, estatus, ingresos: ______________________

10) Temores, protección y factores humanitarios
- ¿Ha sufrido persecución, amenazas, violencia o trata? ______________________
- ¿Es víctima de delito en EE. UU. y cooperó o coopera con autoridades? ______________________
- ¿Ha sufrido violencia doméstica por cónyuge/padre/hijo ciudadano o residente? ______________________
- ¿Teme regresar a su país? Explique motivos, fechas y actores: ______________________

11) Objetivos y plazos
- Objetivo(s) principal(es): [ ] Ajuste de estatus [ ] Trámite consular [ ] Naturalización [ ] Asilo/retención/CAT [ ] TPS/DACA [ ] U/T/VAWA/SIJS [ ] Parole [ ] Perdones [ ] Otro: __________
- Plazos críticos (vencimiento de I‑94/DS‑2019/EAD/estadía, audiencias, RFE/NOID, fechas consulares): ______________________

12) Comunicaciones y autorizaciones
- Preferencia de contacto: [ ] Teléfono [ ] Correo [ ] Mensajería segura
- Autorizo comunicaciones electrónicas conscientes de sus riesgos razonables: [ ] Sí [ ] No
- Autorizo al despacho a:
  - Solicitar expedientes migratorios y gubernamentales (FOIA/PA) ante USCIS, CBP, ICE, EOIR, DOS, u otras agencias, en mi nombre: [ ] Sí [ ] No
  - Contactar a abogado(s) previo(s) para obtener mi archivo: [ ] Sí [ ] No

13) Conflictos de interés y verificación
- Liste a cualquier otra persona involucrada potencialmente en su caso (cónyuge/expareja/peticionario/empleador): ______________________
- Documento de identidad con foto adjunto para verificación: [ ] Sí [ ] No

14) Declaración del cliente
Declaro que la información proporcionada es veraz y completa a mi leal saber y entender. Comprendo que la evaluación legal depende de estos datos y que aportar información falsa u omitir hechos materiales puede perjudicar mi caso y exponerme a sanciones legales. Entiendo que este formulario no constituye asesoría legal definitiva ni crea relación abogado-cliente sin un acuerdo escrito de representación.

- Firma del cliente: ______________________
- Nombre en letra de molde: ______________________
- Fecha: ______________________
- Si se utilizó intérprete:
  - Nombre del intérprete: ______________________
  - Idioma: ______________________
  - Firma del intérprete: ______________________
  - Fecha: ______________________

Para uso interno del despacho
- Fecha de recepción: ______________________
- Abogado/a responsable: ______________________
- Verificación de conflictos: [ ] Limpio [ ] Potencial conflicto (requiere consentimiento informado)
- Alertas de plazo: ______________________
- Evaluación preliminar de vías de alivio: ______________________
- Documentación faltante solicitada el: ______________________

Lista de verificación de documentos a adjuntar (copias legibles)
- Identificación y viaje: pasaporte (página biográfica y sellos), I‑94, visas, permisos de reingreso, documentos de identidad nacionales.
- Estado civil y familiar: certificados de nacimiento, matrimonio, divorcio, defunción; evidencia de relaciones bona fide (contratos de arrendamiento, cuentas conjuntas, fotos, comunicaciones).
- Historial migratorio: NTAs, órdenes de corte, decisiones de USCIS/BIA, recibos, RFEs/NOIDs y respuestas, evidencia de entradas/salidas.
- Penal: informes policiales, denuncias, minutas, sentencias, comprobantes de cumplimiento.
- Empleo e impuestos: cartas laborales, talones de pago, W‑2/1099, declaraciones de impuestos (últimos 3 años), cartas de empleador, licencias profesionales.
- Educación: diplomas, certificados, evaluaciones de credenciales (si aplica).
- Salud: registros médicos relevantes, cartilla de vacunación.
- Evidencia humanitaria: informes, declaraciones juradas, órdenes de protección, reportes de investigación policial, pruebas de cooperación.

Nota final
Proporcione la información y documentación solicitadas con la mayor precisión posible. La integridad de este formulario permitirá una evaluación jurídica conforme a los estándares profesionales y a las exigencias normativas aplicables.