Instrument - Immigration Legal Services for Afghan Arrivals - Eligible Afghan Arrivals Intake Form_clean

Immigration Legal Services for Afghan Arrivals (ILSAA) Eligible Afghan Arrival (EAA) Intake Form

OMB Control No.: XXXX-XXXX

Expiration Date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT (PRA) OF 1995 (Pub. L. 104–13) The purpose of this information collection is to verify the eligibility of Afghan Arrivals to receive legal services through the Immigration Legal Services for Afghan Arrivals project, an Office of Refugee Resettlement initiative. Public reporting burden for this collection of information is estimated to average five minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. A federal agency may not conduct or sponsor, and no individual or entity is required to respond to, nor shall an individual or entity be subject to a penalty or failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless that collection of information displays a currently valid OMB control number. If you have any comments on this collection of information, please contact Thomas Wetterhan, Operations Director, ICF, by email at Thomas.Wetterhan@icf.com.

Thank you for your interest in Immigration Legal Services for Afghan Arrivals (ILSAA). Please provide the information below to help us determine if you qualify for legal services under our project. Completing this form is voluntary and you can decline to answer any questions. Information will be shared privately with ILSAA staff and may be shared with the Office of Refugee Resettlement. Aggregate data without any of your personally identifiable information may be shared with partner organizations to improve services provided to you and other Afghans. This form should take about five minutes to complete.

If you qualify, you will receive a call from our intake or legal teams to collect additional information and connect you with an attorney.

1. First Name: _______________

2. Middle Name: _______________

3. Last Name: ____________

4. Date of Birth: ____________ (date selector)

5. Street Address: ___________________

6. City: ________________

7. State: ____________________ (drop-down list)

8. ZIP Code: ____________

9. Phone Number: ____________

10. Email Address: ____________

11. What is your preferred language? (drop-down list)

• Dari

• Pashto

• English

• Uzbek

• Arabic

• Urdu

• Other, please specify ______ (write in)

12. Are you currently located in the United States?

• Yes

• No

13. Date of Entry into the US: ____________ (skip if Q12 is No)

14. Were you paroled into the United States under Operation Allies Welcome (OAW)?

• Yes

• No

• I don’t know

15. What is your current I-94 status? ____________

16. I-94 Expiration Date: ____________ (date selector)

17. Do you have an Employment Authorization Document (EAD)?

• Yes

• No

• I don’t know

18. EAD Expiration Date: ____________ (date selector)

19. Have you ever received a Notice to Appear in Immigration Court?

• Yes

• No

• I don’t know

20. Have you ever filed an application for the United States Citizenship and Immigration Services (USCIS)?

• Yes

• No

• I don’t know

By clicking “submit” you consent to provide your personal information to help us determine if you qualify for legal services through ILSAA.