IN-TAKE FORM

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IN-TAKE FORM

IN-TAKE FORM | For assistance download this file: bit.ly/ftspexample

Email *

Full Name *

Date of Birth *

YYYY

Age *

What Country Were You Born In? *

Alien Number *

Address *

Phone Number *

Have you received a removal order? *

Yes

I don't know

Other:

If you answered yes, where and when?

Please describe your immigration detention history. Where were you detained and for how long? If you have never been detained by I.C.E please enter N/A. *

When was your last check-in date *

YYYY

What is your check-in status? *

When did you arrive to the USA?

YYYY

Do you have an immigration attorney? *

Yes

If yes, please name your attorney and firm. If you don't have one please enter N/A. *

What is your personal history and grounds for a pardon? *

Case information. Please explain your case. *

Prison Information. Please explain your time in prison and how you made use of your time. *

Immigration Case. *

Explain your life after prison. *

Extraordinary Circumstances. Describe the harms or disadvantage to you, your family, and community that would be caused due to your deportation. Please be specific and detailed as possible. *

Please list all of your prior convictions that need pardoned. *

Date and time of Conviction *

YYYY

Sentenced Received.

Did you take a plea deal or go to trial? *

Plea Deal

Trial

Other:

Were you advised of immigration consequences? *

Yes

Other:

If you were advised of immigration consequences when were you given advice?

YYYY

Restitution Paid? *

Yes

List any prior convictions that does not need a pardon. If none please enter N/A *

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