Asylum Questionnaire | Messersmith Law Firm

SECTION 01 · CLIENT INTAKE

Contact information

Only your first name, last name and email are required. All other questions in this intake are optional.

Your first name *

Your last name *

Your email address *

Preferred telephone number

Person completing questionnaire

SECTION 02 · CLIENT INTAKE

Applicant identity — Form I-589 Part A.I

Answer as completely as you can. All questions in this section are optional.

Given name (first name) on passport

Middle name

Complete family name (last name)

A-number(s), if any

US Social Security number (if any)

USCIS online account number

Full name in native alphabet

City / town of birth

Country of birth

Current nationality / citizenship

Nationality at birth

Race / ethnic / tribal group

Religion

Native language and dialect

Other languages spoken fluently

Current occupation

Other names ever used (maiden names, aliases, alternate spellings)

Entry 1

Full name used

Approximate dates used

Reason / context

Do you have a current spouse?

Do you have any children (of any age)?

Date of birth

Sex as reflected on government form

Marital status

Fluent in English?

SECTION 03 · CLIENT INTAKE

US residence, mailing address and travel documents — Part A.I

Answer as completely as you can. All questions in this section are optional.

US physical street address

US apartment or unit

US residence city

US residence state

US residence ZIP code

Mailing address: in care of

Mailing address street

Mailing address unit

Mailing address city

Mailing address state

Mailing address ZIP code

Residence telephone

Mailing address telephone

Date last departed country of claimed persecution (if known)

Most recent I-94 number

Country issuing most recent passport/travel document

Passport number

Travel document number

Passport or travel document expiration date

Are you physically present in the United States?

Is your mailing address different from your residence?

SECTION 04 · CLIENT INTAKE

US entries, immigration history and court proceedings — Part A.I

Answer as completely as you can. All questions in this section are optional.

Immigration Court proceedings

All entries into the United States (most recent first)

Entry 1

Entry date

Port / place of entry

Immigration status on entry

Status expiration date

I-94, if known

Admitted, paroled or other

Immigration court and prior removal proceedings

Entry 1

Court / location

A-number / docket

Dates

Status / results

Have you ever received a Notice to Appear (NTA)?

Have you ever been ordered removed, deported or excluded?

Current US immigration status and relevant background

Anything else about admission, parole, CBP processing or last arrival?

SECTION 05 · CLIENT INTAKE

Spouse details — Part A.II

Complete this if you are married. The person’s presence and inclusion in the asylum claim are recorded separately.

Spouse first name

Spouse middle name

Spouse last name

Other names spouse has used

Spouse A-number

Spouse SSN

Spouse passport or identity card number

Place of marriage

Spouse city and country of birth

Spouse citizenship

Spouse race, ethnicity or tribal group

Spouse current location, if abroad

Spouse last US entry place

Spouse I-94 number

Spouse immigration status upon last admission

Spouse current immigration status

Spouse date of birth

Date of marriage

Spouse last US entry date

Spouse authorized stay expiration

Spouse previous US arrival date

Spouse sex

Is spouse now in the US?

Is spouse in Immigration Court proceedings?

Include spouse as a derivative in this application (if eligible)?

SECTION 06 · CLIENT INTAKE

Children — Part A.II and Supplement A

List all children regardless of age, marital status or country. Use Add another child for additional children.

All children

Entry 1

First name

Middle name

Last name

Date of birth

City and country of birth

Citizenship

A-number

SSN

Passport/ID

Marital status

Race / ethnic / tribal group

Sex

In the US?

Location if outside the US

Last US entry date

Last US entry place

I-94 number

Status on entry

Current US status

Authorized stay expiration

Immigration court proceedings?

Include as derivative (if eligible)?

Other information about your children or who may qualify as a derivative

SECTION 07 · CLIENT INTAKE

Residential addresses and previous foreign residence — Part A.III

Answer as completely as you can. All questions in this section are optional.

Last residence before entering the US and last address in feared country

Entry 1

Street

City/town

Province/state

Country

From (month/year)

To (month/year)

Most recent residence or location of feared harm

Addresses during the past five years

Entry 1

Street

City

State/province

Country

From month/year

To month/year

SECTION 08 · CLIENT INTAKE

Education and employment — Part A.III

Answer as completely as you can. All questions in this section are optional.

Education (most recent first)

Entry 1

School name

School type

School address

From month/year

To month/year

Credential / degree

Employment in the past five years

Entry 1

Employer name

Employer address

Occupation

From month/year

To month/year

Additional details

SECTION 09 · CLIENT INTAKE

Parents and brothers/sisters — Part A.III

Answer as completely as you can. All questions in this section are optional.

Mother, father and all siblings

Entry 1

Mother / father / brother / sister

Full name

City and country of birth

Current residence or location

Deceased?

Other relevant information

SECTION 10 · CLIENT INTAKE

Protection requested and legal grounds — Part B

Answer as completely as you can. All questions in this section are optional.

Protection requested

Is Race a basis of your claim?

Is Religion a basis of your claim?

Is Nationality a basis of your claim?

Is Political opinion a basis of your claim?

Is Membership in a particular social group a basis of your claim?

Is Torture / Convention Against Torture a basis of your claim?

Detailed summary of asylum / withholding / CAT claim

Why do you believe you were or would be targeted for a protected reason?

Describe any particular social group you are claiming

Country condition and incident evidence available (or why unavailable)

SECTION 11 · CLIENT INTAKE

Past harm, threats and mistreatment — Part B.1.A

Answer as completely as you can. All questions in this section are optional.

Have you, relatives, close friends or colleagues experienced harm, mistreatment or threats?

Each incident of past harm or threats

Entry 1

Date or period

Country/city/location

Person affected

What happened?

Who caused or threatened harm?

Why do you believe it happened?

Report to police / government?

Supporting evidence / witnesses

Additional narrative of past harm, threats, physical injuries, losses and lasting impacts

SECTION 12 · CLIENT INTAKE

Fear of future harm and relocation — Part B.1.B

Answer as completely as you can. All questions in this section are optional.

Do you fear harm or mistreatment if returned to your home country?

Describe in detail the harm you fear

Who would harm or mistreat you and why?

Why does the feared harm relate to race, religion, nationality, political opinion or social group?

Why would government officials be unable or unwilling to protect you?

Could you avoid the harm by relocating elsewhere in the home country? Explain.

Relevant changes or ongoing conditions in the home country

SECTION 13 · CLIENT INTAKE

Detention, accusations and organizations — Part B.2–3

Answer as completely as you can. All questions in this section are optional.

Have you or family been accused, charged, arrested, detained, interrogated, imprisoned or sentenced outside the US?

Foreign arrests, detention, charges, convictions and other incidents

Entry 1

Person involved

Country / location

Approximate date

Action and circumstances

Outcome / sentence

Stated reasons

Have you or family belonged to or been associated with any political, religious, student, labor, military, media, human rights or other groups?

Membership and association history

Entry 1

Person

Organization or group

Type / purpose

Role or leadership

Joined / from

Ended / to

Still involved?

Nature of activity

Do you or family currently participate in any groups described above?

Other relevant associations and activity

SECTION 14 · CLIENT INTAKE

Torture risks — Part B.4

Answer as completely as you can. All questions in this section are optional.

Do you fear torture in your home country or another country to which you could be returned?

Nature and severity of torture you fear

Who would carry out the torture?

Why would the torture be inflicted?

Government involvement, consent or acquiescence

Past torture and relevant evidence

SECTION 15 · CLIENT INTAKE

Prior asylum and protection filings; travel through other countries — Part C.1–2

Answer as completely as you can. All questions in this section are optional.

Have you or close family ever applied for refugee status, asylum or withholding in the US?

Prior asylum, withholding, refugee filings

Entry 1

Person

Agency / tribunal

Date

A-number

Case number

Decision / status

Changes after prior denial

After leaving the country of feared harm, did you, spouse or children stay in or travel through another country before the US?

Transit and third country residence

Entry 1

Person

Country

Dates and length of stay

Immigration status

Why left

Right to return for lawful residence?

Sought asylum/refugee protection?

If not, why not?

Have you or family applied for or received lawful status in another country?

Details of foreign lawful residence, nationality, status and entitlements

SECTION 16 · CLIENT INTAKE

Participation in harm; return travel — Part C.3–4

Answer as completely as you can. All questions in this section are optional.

Have you, spouse or children ever ordered, incited, assisted or participated in harming others for a protected reason?

For each person and incident, describe involvement and circumstances

After leaving the country where you fear harm, did you return there?

Trips back to the country of feared harm

Entry 1

Date(s)

Country and destination

Purpose of visit

Duration of visit

Circumstances of trip and return

SECTION 17 · CLIENT INTAKE

One-year filing question and criminal history — Part C.5–6

Answer as completely as you can. All questions in this section are optional.

Is or will this I-589 be filed more than one year after the last arrival in the US?

If after one year, explain exceptional/changed circumstances or other reasons and exact timeline

Relevant dates for one-year filing issue

Entry 1

Date

Event (entry, status, change, disruption, filing)

Available supporting evidence

Have you or family included in the application committed a crime, or been arrested, charged, convicted or sentenced in the US (including immigration violations)?

US arrests, charges, convictions or detention

Entry 1

Person

Date

Location

Conduct and allegation

Charges

Sentence / custody duration

Reason for release / disposition

Court/police documents available

SECTION 18 · CLIENT INTAKE

Supporting materials, related issues and additional information — Part D / Supplement B

Answer as completely as you can. All questions in this section are optional.

Did spouse, parent or children help with gathering information for this intake?

Names and relationships of family members assisting with this intake

Have you been given information about low or no-cost immigration representation?

List identity, entry, family, incident, medical, police, membership, country conditions and other evidence available

Evidence unavailable and reasons

Documents requiring certified translation

Additional facts or explanations, including I-589 page, part and item if applicable

SECTION 19 · CLIENT INTAKE

Review and submit

Review all answers before submitting. Only first name, last name and email are mandatory. This intake is not a government filing.

Anything else our office should know about this asylum matter?

Asylum & Protection Questionnaire

Contact information

Applicant identity — Form I-589 Part A.I

US residence, mailing address and travel documents — Part A.I

US entries, immigration history and court proceedings — Part A.I

Spouse details — Part A.II

Children — Part A.II and Supplement A

Residential addresses and previous foreign residence — Part A.III

Education and employment — Part A.III

Parents and brothers/sisters — Part A.III

Protection requested and legal grounds — Part B

Past harm, threats and mistreatment — Part B.1.A

Fear of future harm and relocation — Part B.1.B

Detention, accusations and organizations — Part B.2–3

Torture risks — Part B.4

Prior asylum and protection filings; travel through other countries — Part C.1–2

Participation in harm; return travel — Part C.3–4

One-year filing question and criminal history — Part C.5–6

Supporting materials, related issues and additional information — Part D / Supplement B

Review and submit

Secure submission