Meet & Greet Interview/Cheat Sheet: VAWA​

Based on: Spouse - U.S. LPR

Parent Child
With Waiver: With derivative: if so #__________
Type of Case and Tier: __________________________________

Meet & Greet Name: ____________________________ Interview Date: _________________

When you complete the information on this sheet, fill it out as you would on the forms so we
can copy and paste it onto the forms. ​

Any deadline that needs to be flagged​

Court Hearing: Master Individual Date: ____________________________​
Death Certificate Date: ____________________________​
Divorce Date: ____________________________​
Deadline Additional Notes: ​
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________​

Biographical Information: ​
Client’s ph#: __________________ Email:_________________
Does the client need an Interpreter? Yes No

Client’s Last name: ________________________________________________ ​

Client’s First Name: _________________
Client’s Middle Name: ______________________
Other names used: ___________________________________________________________
Date of birth: _______________________ ​
Have you Ever Used any other date of birth: Yes No If yes, list them: __________________​

City of birth: ____________________

Client sex: Male Female
Ethnicity: Hispanic/ Latino Not Hispanic/ Latino
Race: Asian Black/African American American Indian/ Alaska Native
Native Hawaiian or other Pacific Islander White
Height Feet _______ Inches _____ Weight Pounds ______​
Eye Color Black Blue Brown Gray Green Hazel Marron Pink
Unknown/Other
Hair Color Bald (No hair) Black Blond Brown Gray Red Sandy
White Unknown/Other ​
​
Has the client Ever applied for EAD? Yes NO If so, how it was obtained:
___________________________________​
A#: _________________ SSN: ______________________ ​
​
Have you Ever Used or been assigned any other A- Number? Yes NO ​
If yes, A-_____________________, A-_____________________ A-_____________________.​

Additional Information About Applicant

Have you ever applied for an immigrant visa to obtain permanent residence status at the U.S.
Embassy or U.S. Consulate abroad? Yes No
If Yes, provide the following: ​
Location of U.S. Embassy or U.S. Consulate: City/Country: __________________________
Decision (Approved, Deny, Refused, Withdrawn): ________________________________________​
Date of Decision: ____________________________________

Have you previously applied for permanent residence while in the U.S.? Yes No
Have you ever held LPR status, which was later rescinded under INA Section 246? Yes No

Parents Information ​
​
Mother’s First/Middle/Last name:________________________________________________​
Mother’s DOB: _____________________
Country of birth:_______________________​
​
Father’s First/Middle/Last name:_________________________________________________​
Father’s DOB: _____________________
Country of birth:_________________________​
​
Child Based
N/A ​
Relationship: Biological Mother or Biological Father ​
Step Mother or Step Father ​
Abuser’s Full Name: ___________________________________________​
Date of Birth: ______________ Place of birth city/state/country: _______________​
Legal status: USC by birth Naturalized USC A#: __________ LPR: A#: ____________
​
Dates lived with Abuser in total: From: _____________________ To ______________________​
Address of last place living together: _______________________________________________ ​
Dates lived at this address with abuser: From _________________ To ____________________​
​
Address of last place living together: _______________________________________________ ​
Dates lived at this address with abuser: From _________________ To ____________________​
​
Address of last place living together: _______________________________________________ ​
Dates lived at this address with abuser: From _________________ To ____________________​
​
Address of last place living together: _______________________________________________ ​
Dates lived at this address with abuser: From _________________ To ____________________​
​
# of times Applicant has been married: _______ # of times Abuser has been married: ________​
​
Past 5 years of residence

1)​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________
With Spouse/Child/ Parent Y N

2)​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________
With Spouse/Child/ Parent Y N

3)​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________
With Spouse/Child/ Parent Y N

4)​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________
With Spouse/Child/ Parent Y N
 5)​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________
With Spouse/Child/ Parent Y N
​
Last address outside of the US:
Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________
With Spouse/Child/ Parent Y N
​
Past 5 years of employment:​

1)​ Employer ________________________________

Occupation _____________________________​
​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________

2)​ Employer ________________________________

Occupation _____________________________​
​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________

3)​ Employer ________________________________

Occupation _____________________________​
​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________

4)​ Employer ________________________________

Occupation _____________________________​
​ Address_______________________________
City/State/Zip _______________________________
From _____________________ To _____________________

5)​ Employer ________________________________

Occupation _____________________________​
​ Address_______________________________
City/State/Zip _______________________________
 From _____________________ To _____________________

If unemployed or retired, source of financial support:​

________________________________________________________________________________​

Last employer outside the US:​

Employer’s Name: ________________________________ Occupation:_____________________________​

Address:_______________________________ City/State/Zip:_______________________________
From: _____________________ To:_____________________ ​

Entries/Departures ​
Client's age at the time of first entry: ________________ Date of last arrival: ______________
Place of entry:__________________________________
Status at entry: ______________ Manner of entry: __________
Only fill this information out if the client’s last entry was lawful with a visa, etc.; don’t complete if the
last entry was EWI ​
Passport Number: ____________________________
I-94 Number: ____________________________
Travel Document Number: ____________________________​

If only one entry is provided. Was your last arrival the first time you were physically present in
the United States? Yes NO

Have you ever been issued an “alien crewman” visa? Yes NO

Did you last arrive in the United States to join a vessel as a seaman or crewman or whistle
serving in any capacity abroad a vessel or aircraft? Yes NO

Other entries
Date of entry #1 Status at entry/Manner Place of entry Knew Spouse/Child/ Parent
Yes NO
Contact with immigration/outcome:​
___________________________________________________________________________________________​
Date of departure/Reason for departure:​
___________________________________________________________________________________________
Date of entry #2 Status at entry/Manner Place of entry Knew Spouse/Child/ Parent
Yes NO
Contact with immigration/outcome:​
___________________________________________________________________________________________
Date of departure/Reason for departure:​
___________________________________________________________________________________________
Date of entry #3 Status at entry/Manner Place of entry Knew Spouse/Child/ Parent
Yes NO
Contact with immigration/outcome:​
___________________________________________________________________________________________​
Date of departure/Reason for departure:​
___________________________________________________________________________________________
Date of entry #4 Status at entry/Manner Place of entry Knew Spouse/Child/ Parent
Yes NO
Contact with immigration/outcome:​
___________________________________________________________________________________________
Date of departure/Reason for departure:​
___________________________________________________________________________________________
Date of entry #5 Status at entry/Manner Place of entry Knew Spouse/Child/ Parent
Yes NO
Contact with immigration/outcome:​
___________________________________________________________________________________________​
Date of departure/Reason for departure:​
___________________________________________________________________________________________

Spouse’s information
Last name: ​ First name:
Middle name: ​DOB:
Place of birth city/state/country: ________________________________________________
Date of marriage:______________________ Place of marriage:____________________

Spouse Based ​
N/A
Legal status: USC by birth USC naturalized A#: ______________LPR A#____________​

Dates lived with Abuser in total: From: ___________ To ___________

Address of last place living together: ____________________________________________
Dates lived at this address with an abuser: From To __________________​

Address of last place living together: ____________________________________________

Dates lived at this address with an abuser: From To __________________​

Address of last place living together: ____________________________________________

Dates lived at this address with an abuser: From To __________________​
​
# of times Applicant has been married: # of times Abuser has been married: __________ ​
When did you meet your spouse? __________ When did you start dating? ​ ​
​
Information about Applicant’s previous spouses
Full name: ___________________________________________________________________
DOB: ​ Country of Birth: _________________
Country of Citizenship or Nationality: _______________________ ​
Date of Marriage: ______________ Place of marriage city/state/country: ________________________
Date marriage legally ended: ________________________________________________
City/state/country marriage legally ended: __________________________________________
How Marriage Ended with Prior Spouse: Annulled Divorced Spouse Deceased ​
Other: ______________________________

Full name: ___________________________________________________________________

DOB: ​ Date of Marriage: _________________________
Place of marriage city/state/country: ____________________________________________
Date marriage legally ended: ________________________________________________
City/state/country marriage legally ended: __________________________________________ ​
How Marriage Ended with Prior Spouse: Annulled Divorced Spouse Deceased ​
Other: ______________________________​

Information about Spouse's Previous Marriage ​

Full name: ___________________________________________________________________
DOB: ​ Date of Marriage: _________________________
Place of marriage city/state/country: ____________________________________________
Date marriage legally ended: ________________________________________________
City/state/country marriage legally ended: __________________________________________
How Marriage Ended with Prior Spouse: Annulled Divorced Spouse Deceased ​
Other: ______________________________
​
Parent Based
N/A ​
Abuser Child’s Last name: _____________First name: ____________ Middle name: ​ ​
Legal status: USC by birth USC naturalized A#: ______________
DOB: ______________ Place of Birth city/state/country:: ______________​
Is this child a biological child Step-child Adopted
Joint Case/Child with Current Spouse or Child from Previous Relationship: __________________
​
Dates lived with Abuser in total: From: _____________________ To ______________________
Address of last place living together: _______________________________________________
Dates lived at this address with abuser: From _________________ To ____________________ ​
​
Address of last place living together: _______________________________________________
Dates lived at this address with abuser: From _________________ To ____________________ ​
​
Address of last place living together: _______________________________________________
Dates lived at this address with abuser: From _________________ To ____________________
# of times Applicant has been married: _______ # of times Abuser has been married: ________​
​
Applicant Children’s Information (list all joint children, stepchildren, and children of Applicant,
even if the children live in other countries) Start from oldest to youngest​
​
Last name: __________________First name: __________ Middle name: ​ ​
Country of birth: ​ Current legal status (A# if applicable): _______________
DOB: ______________ ​
Is this child a joint child/step/from a previous relationship? _________________​

Last name: __________________First name: __________ Middle name: ​ ​

Country of birth: ​ Current legal status (A# if applicable): _______________
DOB: ______________
Is this child a joint child/step/from a previous relationship? _________________​

Last name: __________________First name: __________ Middle name: ​ ​

Country of birth: ​ Current legal status (A# if applicable): _______________
DOB: ______________
Is this child a joint child/step/from a previous relationship? _________________​

Last name: __________________First name: __________ Middle name: ​ ​

Country of birth: ​ Current legal status (A# if applicable): _______________
DOB: ______________
Is this child a joint child/step/from a previous relationship? _________________​

Last name: __________________First name: __________ Middle name: ​ ​

Country of birth: ​ Current legal status (A# if applicable): _______________
DOB: ______________
Is this child a joint child/step/from a previous relationship? _________________​

Last name: __________________First name: __________ Middle name: ​ ​

Country of birth: ​ Current legal status (A# if applicable): _______________
DOB: ______________
Is this child a joint child/step/from a previous relationship? _________________​

Last name: __________________First name: __________ Middle name: ​ ​

Country of birth: ​ Current legal status (A# if applicable): _______________
DOB: ______________
Is this child a joint child/step/from a previous relationship? _________________​
Criminal History & Arrests
List every arrest or citation by any agency, including border patrol, list date, location, the
reason for arrest/charges, punishment such as jail time, probation, etc., outcome, and current
disposition: closed or open.​

Date City/State/Country Charges

Outcome/Sentence:___________________________________________________________________
Is the case closed? Did CL comply with everything court-ordered? Yes NO
Notes:_________________________________________________________________________________
______________________________________________________________________________________

Date City/State/Country Charges

Outcome/Sentence:___________________________________________________________________
Is the case closed? Did CL comply with/ everything the court ordered? Yes NO
Notes:_________________________________________________________________________________
______________________________________________________________________________________

Date City/State/Country Charges

Outcome/Sentence:___________________________________________________________________
Is the case closed? Did CL comply with/ everything the court ordered? Yes NO
Notes:_________________________________________________________________________________
______________________________________________________________________________________

Date City/State/Country Charges

Outcome/Sentence:___________________________________________________________________
Is the case closed? Did CL comply with/ everything the court ordered? Yes NO
Notes:_________________________________________________________________________________
________________________________________________________________________________________

Date City/State/Country Charges

Outcome/Sentence:___________________________________________________________________
Is the case closed? Did CL comply with/ everything the court ordered? Yes NO
Notes:_________________________________________________________________________________
______________________________________________________________________________________​
​
Inadmissibility Questions​
​
General eligibility questions ​

10. Have you EVER been denied admission to the United States?Yes NO
11. Have you EVER been denied a visa to the United States?Yes NO
12. Have you EVER worked in the United States without authorization?​
Yes NO
13. Have you EVER violated the terms or conditions of your nonimmigrant status?​
Yes NO
14. Are you presently or have you EVER been in removal, exclusion, rescission, or
deportation proceedings? Yes NO
15. Have you EVER been issued a final order of exclusion, deportation, or removal?
Yes NO
16. Have you EVER had a prior final order of exclusion, deportation, or removal
reinstated? Yes NO
17. Have you EVER been granted voluntary departure by an immigration officer or an
immigration judge but failed to depart within the allotted time? Yes NO
18. Have you EVER applied for any kind of relief or protection from removal,
exclusion, or deportation?Yes NO
19. Have you EVER been a J nonimmigrant exchange visitor who was subject to the
two-year foreign residence requirement? Yes NO
20. If you answer “YES” to Item Number 19., have you completed the foreign
residence requirement? Yes NO
21. If you answer “YES” to Item Number 19., and “No” to Item Number 19., have you
been granted a waiver, or has the Department of State issued a favorable waiver
recommendation letter for you? Yes NO
​
Criminal Act and Violations Questions ​
​
22. Have you EVER been arrested, cited, charged, or permitted to participate in a
diversion program (including pre-trial diversion, deferred prosecution, deferred
adjudication, or any wild adjudication) or detained for any reason by any law
enforcement official in any country including to any U.S. immigration official or any
official of the U.S. armed forces or U.S. Coast Guard) or by a similar official in a
country other than the United States? Yes NO ​
23. Have you EVER committed a crime of any kind (even if you were not arrested,
cited, charged with, or tried for that crime or convicted)? Yes NO
24. Have you EVER pled guilty to or been convicted of a crime or offense (even if the
violation was subsequently expunged or sealed by a court, or if you were granted a
pardon, amnesty, a rehabilitation decree, or other act of clemency)? Yes NO
25. Have you EVER been ordered punished by a judge or had conditions imposed on
you that restrained your liberty (such as a prison sentence, suspended sentence,
house arrest, parole, alternative sentencing, drug or alcohol treatment, rehabilitative
programs or classes, probation, or community service)? Yes NO ​
26 . Have you EVER violated (or attempted or conspired to violate) any controlled
substance law or regulation of a state, the United States, or a foreign country?​
Yes NO ​
27. Have you EVER trafficked in or benefited from or knowingly aided, abetted,
conspired, or colluded in the illegal trafficking of controlled substances, such as
chemicals, illegal drugs, or narcotics? Yes NO
28. Are you the spouse, son, or daughter of a foreign national who illicitly trafficked
or aided (or otherwise abetted, assisted, conspired, or colluded) in the illicit
trafficking of a controlled substance, such as chemicals, illegal drugs, or narcotics
and you obtained, within the last five years, any financial or other benefit from the
illegal activity of your spouse or parent? Yes NO
29. If your answer to Item Number 28 is “YES,” did you know or should you have
reasonably known that the financial or other benefit you obtained resulted from this
activity of your spouse or parent? Yes NO
30. Have you EVER engaged in prostitution, or are you coming to the United States to
engage in prostitution? Yes NO
31. Have you EVER directly or indirectly procured (or attempted to procure) or
imported prostitutes or persons for the purpose of prostitution? Yes NO
32. Have you EVER received any proceeds or money from prostitution? ​
Yes NO
33. Do you intend to engage in illegal gambling or any other form of commercialized
vice, such as prostitution, bootlegging, or the sale of child pornography, while in the
United States? Yes NO
34. Have you EVER exercised immunity (diplomatic or otherwise) to avoid being
prosecuted for a criminal offense in the United States? Yes NO
35 .a.. Have you EVER served as a foreign government official? Yes NO
35.b. If your answer to Item Number 35. a. Is it “YES”? Have you EVER been
responsible for, enforced, or directly carried out violations of religious freedoms? ​
Yes NO
36. Have you EVER induced by force, fraud, or coercion (or otherwise been involved
in) the trafficking of persons for commercial sex acts(sex trafficking)? ​
Yes NO
37. Have you EVER trafficked a person into involuntary servitude, peonage, debt
bondage, or slavery? Yes NO
38. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with
others in trafficking persons for commercial sex acts or involuntary servitude,
peonage, debt bondage, or slavery? Yes NO
3 9. Are you the spouse, son, or daughter of a foreign national who engaged in the
trafficking of persons and has received or obtained, within the last five years, any
financial or other benefits from the illicit activity of your spouse or your parent,
although you knew or reasonably should have known that this benefit resulted from
the illicit activity of your spouse or parent? Yes NO
40. If your answer is “YES” to Item number 39., did you know or reasonably should
have known that this benefit resulted from this activity of your spouse or parent?​
Yes NO
41. Have you EVER engaged in money laundering, or have you EVER knowingly aided,
assisted, conspired, or colluded with others in money laundering, or do you seek to
enter the United States to engage in such activity? Yes NO ​
​
Security And Related ​
​
42.a. Engage in any activity in the United States that violates or decades any law
relating to espionage (including spying) or Sabotage in the United States?​
Yes NO
42.b Engage in any activity in the United States that Violates or evades any law
prohibiting the export of goods, technology, or sensitive information from the United
States. Yes NO ​
42.c. Engage in any activity whose purpose includes opposing controlling the U.S.
government by force, violence, or other unlawful means while in the United States. ​
Yes NO
42.d. Engage in any other unlawful activity? Yes NO
​
Have you EVER: ​
​
43. a Received any weapons training, paramilitary training, or other military-type
training? Yes NO ​
43.b. Committed Kidnapping, assassination, or hijacking or sabotage of a
conveyance (including an aircraft, vessel, vehicle, or train)? Yes NO
43.c. Used a weapon or explosive or any dangerous device with the intent to
endanger the safety of another person or people or cause damage to property?​
Yes NO ​
43.d. Threatened, Attempted, conspired, prepared, or planned to do any of the things
described in the Item Item Number 43.b.43.e.? Yes NO ​
43.e. Incited, under circumstance indicating an intention to cause death or serious
bodily harm/injury, any of the activities described in Item numbers 43.b.43.e.?​
Yes NO ​
43.f. Participated in or been a member of a group or organization that did any of the
activities described in Item numbers 43.b.43.e.? Yes NO
43.g. Recruited members or asked for money or things of value for a group or
organization that did any of the activities described in Item numbers 43.b.43.e.?​
Yes NO ​
43.h. Provided money, a thing of value, service labor, or any other assistance or
support for any of the activities described in Item Number 43.b. - 43.e.? ​
Yes NO
43. i. Provided money, a thing of value, service labor, or any other assistance or
support for an individual, group, or organization who did any of the activities
described in Item numbers 43.b.43.e.? Yes NO
44. Do you intend to engage in any activities listed in any part of Item numbers
43.b.43.e.? Yes NO
45. Do you intend to engage in any activity that could endanger the welfare, safety, or
security of the United States? Yes NO
46. Are you the spouse or child of an individual who EVER engaged in any of the
activities listed in Item numbers 43.b.43.e.? Yes NO
47. Have you EVER sold, provided,d, or transported a weapon or assisted any person
in selling, providing, or transporting weapons that you knew or believed would be
used against another person? Yes NO
48. Have you EVER worked, volunteered, or otherwise served in any prison, jail,
prison camp, detention facility, labor camp, or any other place where people were
detained or EVER directed or participated in any other activity that involved detaining
people? Yes NO
49. Have you EVER been a member of, assisted, or participated in any group, unit, or
organization of any kind in which you or other persons used any type of weapon
against any person or threatened to do so? Yes NO ​
50. Have you EVER served in, been a member of, assisted (helped), or participated in
any military or police unit? Yes NO ​
51. Have you EVER served in, been a member of, assisted, or participated in any
military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel
group, guerilla group, militia, insurgent organization, or any other armed group?​
Yes NO ​
52. Have you EVER been a member of, or in any way affiliated with, the Communist
Party or any other totalitarian party (in the United States or abroad)? Yes NO
Have you EVER ordered incited for, committed, assisted, helped with, or otherwise
participated in any of the following:​
53.a. Torture? Yes NO
53.b Genocide? Yes NO
53.c. Killing or trying to kill any person? Yes NO
53.d intentionally and severely injuring or trying a person? Yes NO
54. Have you EVER recruited, enlisted, or used any person under 15 years of age to
take part in hostilities to serve in or help an armed force or group, or attempted or
worked with others to do so? Yes NO ​
55. Have you EVER used any person under 15 years of age to take part in hostilities,
for instance, participating in combat or providing services related to combat(such as
sabotage or serving a courier) or providing support services (such as transporting
supplies), or attempted or worked with others to do so? Yes NO
​
Public charge questions to exempt from VAWA 57-66 ​
​
Illegal Entries and Other Immigration Violations ​
​
67. Have you EVER failed or refused to attend or to remain in attendance at any
removal proceeding filed against you on or after April 1, 1997? Yes NO
68. Have you EVER submitted altered, fraudulent, or counterfeit documentation to
any U.S. government official to obtain or attempt to obtain any immigration benefit,
including a visa or entry into the United States? Yes NO ​
69. Have you EVER lied about, concealed,d or misrepresented any information on an
application or petition to obtain a visa or other documentation required for entry into
the United States, admission to the United States, or any other kind of immigration
benefit? Yes NO
70. Have you EVER falsely claimed to be a U.S. citizen (in writing or in any other
way)? Yes NO
71. Have you EVER been stowaway on a vessel or aircraft arriving in the United
States? Yes NO
72. Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any
foreign national to enter or to try to enter the United States illegally (alien
smuggling)? Yes NO
73. Are you under a final order of civil penalty for violating INA section 274C for the
use of fraudulent documents? Yes NO
​
Removal, Unlawful Presence, or Illegal Reentry after Previous Immigration
Violations​
​
74. Have you EVER been excluded, deported, or removed from the United States, or
have you ever departed the United States on your own after having been ordered
excluded, deported, or removed from the United States? Yes NO ​
75. Have you EVER entered the United States without being inspected and admitted
or paroled? Yes NO ​
76. Since April 1, 1997, have you been unlawfully present in the United States? You
were unlawfully present in the United States if you were present in the United States
after the expiration of the period of stay authorized by the Department of Homeland
Security (DHS) Secretary or were present in the United States without being admitted
or paroled. Yes NO
77. If you answer “Yes” to Item Number 76., was a severe form of trafficking in
persons at least one central reason for your unlawful presence in the United States?
Yes NO ​
​
Since April 1, 1997, have you EVER reentered or attempted to reenter the United
States without being inspected and admitted or paroled after: ​
​
78.a. Having been unlawfully present in the United States for more than a year in the
aggregate on or after April 1,1997? You were unlawfully present in the United States
for more than one year in the aggregate if you count all of the days during all of your
stays that you were present in the United States after the expiration of the period of
stay authorized by the DHS Secretary or were present in the United States without
being admitted or paroled? Yes NO ​
78.b. Having been deported, excluded, or removed from the United States?​
Yes NO ​
​
Miscellaneous Conduct​

79. Do you plan to practice polygamy in the United States? Yes NO

80. Are you accompanying an alien who is inadmissible and who has been certified
by a medical officer as helpless from sickness, mental or physical disability, or
infancy, and who requires your protection or guardianship, as described in INA
section 232(C)? Yes NO
81. Have you EVER assisted in detaining, retaining, or withholding custody of a U.S.
citizen child outside the United States from a person who has been granted custody
of the child? Yes NO
82. Have you EVER voted in violation of any Federal, state, or local constitutional
provision, statute, ordinance, or regulation in the United States? Yes NO
83. Have you EVER renounced U.S. citizenship to avoid being taxed by the United
States? Yes NO ​
​
Have you EVER: ​
​
84.a. Applied for exemption or discharge from training or service in the U.S. armed
forces or in the U.S. National Security training Crorps on the ground that you are a
Foreign national? Yes NO
84.b. Been relieved or discharged from such training or service on the ground that
you are a foreign national? Yes NO
84.c. Been convicted of desertion from the U.S. armed forces? Yes NO ​
85. Have you EVER left or remained outside the United States to avoid or evade
training or service in the U.S. armed forces in time of war or a period declared by the
President to be a national emergency? Yes NO
86. If you answer “Yes” to Item Number 85., what was your nationality or
immigration status immediately before you left (for example, U.S. citizen or national,
lawful permanent resident, nonmigrant, parole, present without admission or parole,
or any other status)? Yes NO
​
​ ​ ​ ​
​
​ ​ ​ ​ Addendum for Waiver

Client’s entries *If additional space is required, include the remaining information in a note*​
N/A ​
Perm Bar ​
Misrep ​
Criminal: ___________________​
​
Total number of entries: ______
​
Number of Entry: _____________​
1. Date You Entered the U.S. (mm/dd/yyyy): ______________________________________
2. Date You Departed the U.S. (mm/dd/yyyy):______________________________________
3. Immigration Status At the Time of Your Reentry Into the U.S.: _______________________​
4. Location at Which You Entered the U.S.:________________________________________
5. The U.S. City or Town Where You Lived:____________________________________________

Number of Entry: _____________​

1. Date You Entered the U.S. (mm/dd/yyyy): ______________________________________
2. Date You Departed the U.S. (mm/dd/yyyy):______________________________________
3. Immigration Status At the Time of Your Reentry Into the U.S.: _______________________​
4. Location at Which You Entered the U.S.:________________________________________
5. The U.S. City or Town Where You Lived:____________________________________________

Number of Entry: _____________​

1. Date You Entered the U.S. (mm/dd/yyyy): ______________________________________
2. Date You Departed the U.S. (mm/dd/yyyy):______________________________________
3. Immigration Status At the Time of Your Reentry Into the U.S.: _______________________​
4. Location at Which You Entered the U.S.:________________________________________
5. The U.S. City or Town Where You Lived:____________________________________________
​
Number of Entry: _____________​
1. Date You Entered the U.S. (mm/dd/yyyy): ______________________________________
2. Date You Departed the U.S. (mm/dd/yyyy):______________________________________
3. Immigration Status At the Time of Your Reentry Into the U.S.: _______________________​
4. Location at Which You Entered the U.S.:________________________________________
5. The U.S. City or Town Where You Lived:____________________________________________​

Number of Entry: _____________​

1. Date You Entered the U.S. (mm/dd/yyyy): ______________________________________
2. Date You Departed the U.S. (mm/dd/yyyy):______________________________________
3. Immigration Status At the Time of Your Reentry Into the U.S.: _______________________​
4. Location at Which You Entered the U.S.:________________________________________
5. The U.S. City or Town Where You Lived:____________________________________________

Number of Entry: _____________​

1. Date You Entered the U.S. (mm/dd/yyyy): ______________________________________
2. Date You Departed the U.S. (mm/dd/yyyy):______________________________________
3. Immigration Status At the Time of Your Reentry Into the U.S.: _______________________​
4. Location at Which You Entered the U.S.:________________________________________
5. The U.S. City or Town Where You Lived:____________________________________________

If the client has Qualifying Relatives? Yes No ​

If Yes, please complete the following info: *If additional space is required, include the remaining
information in a note*​
​
Family Name (Last Name): ________________________________________​
Given Name (First Name): ________________________________________​
Middle Name: ________________________________________
Physical Address: ________________________________________​
Daytime Telephone Number: ________________________________________​
Email Address: ________________________________________
What is your relative's relationship to you? ________________________________________
What is your relative's immigration status? ________________________________________
Relative's A-Number (if any): ________________________________________
Date of Birth (mm/dd/yyyy): ________________________________________

Family Name (Last Name): ________________________________________​

Given Name (First Name): ________________________________________​
Middle Name: ________________________________________
Physical Address: ________________________________________​
Daytime Telephone Number: ________________________________________​
Email Address: ________________________________________
What is your relative's relationship to you? ________________________________________
What is your relative's immigration status? ________________________________________
Relative's A-Number (if any): ________________________________________
Date of Birth (mm/dd/yyyy): ________________________________________
​
Family Name (Last Name): ________________________________________​
Given Name (First Name): ________________________________________​
Middle Name: ________________________________________
Physical Address: ________________________________________​
Daytime Telephone Number: ________________________________________​
Email Address: ________________________________________
What is your relative's relationship to you? ________________________________________
What is your relative's immigration status? ________________________________________
Relative's A-Number (if any): ________________________________________
Date of Birth (mm/dd/yyyy): _____________________________________​
Once we receive all evidence from the client, compare the information gathered during the M&G
interview with the provided documents. Check the corresponding boxes for each available
document. If a document is unavailable or does not apply, mark the "N/A" box. This interview
sheet will be your cheat sheet when reviewing the entire packet.​

Yes No N/A
​ ​ ​ Applicant’s Birth Certificate (w/Translation)
​ ​ ​ Applicant’s Government Issued ID (Passport/Consular ID aka:
Matricula/State ID or DL) ​
​ ​ ​ Marriage Certificate (If applicable)
​ ​ CLM Certificate (If applicable)
​ ​ ​ CLM Letters (If needed)
​ ​ ​ Proof of Abuser’s legal status (BC, Passport, Certificate of Natz,
LPR)

If a letter requesting USCIS to verify legal status is required, please indicate it here:
_______________________________________________________

​ ​ ​ Applicant’s Divorce Decree

​ ​ Spouse’s Divorce Decree
​ ​ ​ For Spouse Based: Birth Certificates of all joint children
w/Applicant’s name listed
​ ​ Co-hab evidence: Review each document and verify the cohabitation and
document dates. Ensure they align with your cheat sheet, as the Team will
rely on it to review the entire packet. Also, confirm that the date and address
match those listed on the interview/cheat sheet.
​ ​ ​ FBI Report

​ ​ GMC (If applicable)

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Additional notes: ​