DEFERRED ACTION INTAKE

Age Requirement:

I am ______years old. My date of birth is ______.

I was or was not under the age of 16 when I came to the US. (circle one)

I was or was not under the age of 31 on 06/15/2012. (circle one)

Physical Presence Requirements (check one, give most exact dates):

 I entered the United States without any documents on ______.

 I entered the Untied States with a visa on ______. My stay expired on ______.

 I have not left the United States between 06/15/2007 and 06/15/2012.

 I left the United States between 06/15/2007 and 06/15/2012. I was out of the country from ______to ______. (give dates)

 I was or was not in the United States on 06/15/2012. (circle one)

Academic/Armed Forces Requirement:

Currently, I am…

 in middle school  in high school  graduated from high school

 obtained a GED  in college  did not complete high school

 graduated from college  have been in the US armed forces or Coast Guard

Report of Criminal Offenses: (circle one)

I have been arrested? Yes No

I have been convicted of a crime? Yes No

I have been convicted as a juvenile? Yes No

I have received a ticket for a traffic offense? Yes No

If you answered yes to any of the questions above, please list all arrests and convictions:

Conviction/Offense/Arrest:

Date:

Sentence:

Conviction/Offense/Arrest:

Date:

Sentence:

DEFERRED ACTION ELIGIBILITY EVALUATION

By: ______Date: ______

_____ Appears to be eligible based on the answers provided and has all documentary evidence.

_____ Appears to be eligible based on the answers provided and but is missing the following documentary evidence:

______

______

______

_____ Appears not to be eligible based on the answers provided because the person…

_____ Is not over 15 and below 31 years of age

_____ Did not enter the US prior to 16th birthday

_____ Does not meet continual presence requirement

_____ Has criminal convictions that clearly make him/her ineligible to

request deferred action

____ Person has a criminal record that requires one-on-one application assistance, and may follow-up with a Catholic Charities BIA Accredited Representative on Friday at 12:30 pm.

_____ Eligibility determination can not be made until person has obtained criminal record check and has a thorough interview with attorney specialized in immigration/criminal issues related to deferred action.