Language: English Spanish ________________ Interpreter: _____________________

DHS Atty: _______________ R. Counsel: _____________________
Pro se

Initial Bond: $______________; No Bond

Age: _______ Marital Status: Single Common law relationship
Legal Marriage Separated/Divorced

Family Ties & Family Immigration Status:
Spouse Mother Brother(s)
______Child(ren) Father Sister(s)
Aunts, Uncles, Cousins ___________________ ___________________

Immigration History:
Entered: ______________ Status: _____________________________________________________
______________________________________________________________________________________

Criminal Record:
___-___-___ : ___________________________ - sentenced __________; served __________ (Admit/Deny)
___-___-___ : ___________________________ - sentenced __________; served __________ (Admit/Deny)
___-___-___ : ___________________________ - sentenced __________; served __________ (Admit/Deny)
___-___-___ : ___________________________ - sentenced __________; served __________ (Admit/Deny)
______________________________________________________________________________________
______________________________________________________________________________________
Prison ? INS; Release date: ____________________

Education & Employment History:

______________________________ ( ) _____________________________ ( ) ______________________________ ( ) _____________________________ ( )

Will reside: w/ _____ at __________________________________________________________________

DHS Requests: $__________________; No Bond R. Requests: $____________________

Relief: COR/LPR COR/NLPR Pre-VR Post VR
Asylum Withholding Torture 209
Registry Adjustment Termination 212(c)/_______

Bond Decision: No Bond (Mandatory/Danger/Flight) O.R. $__________ & _________
Appeal: Waived by Both Reserved by A/I/B Due: ______-______-______

Next Hearing: Master Calendar Group Hearing Individual Calendar Con’t. Bond

for _______-_______-_______ at ______:__________ a.m./p.m.