Client Intake Form | Washington New Americans

Name

First Name

Last Name

Address

City

State

Zip

Country

Email

Put N/A if you do not have an email address

Phone Number

Other Phone Number

Date of Birth

Age

Date you became a permanent resident

See date on “green card”

Gender (Male, Female or Other)

Country of Origin

Primary Language

Are you single, married, divorced, separated, or widowed?

Yearly Household Income

Number of people in your household

Including yourself and those who live separately if they appear on your taxes

Do you receive any public benefits? If yes, which one(s)?

Number of legal permanent resident children (with green cards) under 18 who live with you?

How did you hear about this workshop?

Do you want to receive information about volunteer opportunities?

Yes

No

Please list all addresses where you have lived for the past 5 years

Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.

Address

City

State/Province

Zip/Postal

Country

Lived Here From (Mo/Year)

Lived Here Until (Mo/Year)

Add
Remove

Please list everywhere you have worked or gone to school for the past 5 years

Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.

Employer or School Name

Address

City

State/Province

Zip/Postal

Country

Worked/Attended School Here From (Mo/Year)

Worked/Attended School Here Until (Mo/Year)

Add
Remove

Provide the following information about all your sons and daughters under 18 years old

Include step-children, adopted children, and missing children. Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application.

How Many Times Have You Been Married?

Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.

Name of Spouse

First Name

Last Name

Spouse Date of Birth

Date of Marriage

Date Marriage Ended (if ended)

Spouse’s Immigration Status

U.S. Citizen

Lawful Permanent Resident

OtherOther

Add
Remove

If you’re currently married, does your spouse serve in the U.S. armed forces?

Yes

No

I’m not married

List below ALL TRIPS of 24 hours or more outside of the U.S. in the last 5 years

Include trips to Mexico or Canada. Please fill out the following sections as completely as you can. You will need to have all of this information prepared to fill out the U.S. citizenship application. Make sure to cover the entire 5-year period.

Date Left U.S. (Mo/Date/Yr)

Date Returned (Mo/Date/Yr)

Countries Visited

Total Days Outside of the U.S.

Add
Remove

Since you received your green card, have you ever had a single trip outside the USA that was 6 months (180 days) or longer?

Yes

No

If yes, when? Include dates