Appellate Referral Form, updated 8/20/18Assigned -None-AndrewBenitaGeniaAnthonyLeeMannyMarieMichelleMizueRyanUnassignedOtherAlisaJaneIs this ILS? YesNoInquiry Stage -None-Never contactedNeeds call backWaiting for call back from inquirerWaiting for donationDocuments waiting for reviewWaiting for documentsDeferred – on holdClosed – inactiveClosed – otherClosed – out of scopeIntake Received Via -None-Hotline callWebformEmailOther phone callOtherYour First NameYour Last Name*Your Email*Your Phone NumberClient First NameClient Last NameClient Date of BirthClient Country of Birth -None-AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo (Democratic Rep)Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland (Republic)IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweHong KongWest BankPuerto RicoDemocratic Republic of the CongoBosnia and HerzegovinaNetherlands AntillesIrelandArubaBritish Virgin IslandsBurkina FasoUSARussiaSouth KoreaMyanmarBosnia-HerzegovinaSaint Kitts and NevisSaint LuciaCote d'IvoireSaint Vincent and the GrenadinesViet NamAntigua and BarbudaMexico Micronesia Federated States ofTrinidad and TobagoAlien NumberThis is helpful to check the status of any removal proceedings.Client Manner of Entry -None-Green Card / Lawful Permanent Resident StatusEntry Without InspectionTemporary VisaRefugee / AsyleeOtherUnknownManner of Entry (if Other)Client Date of Initial EntryClient Current Immigration Status* -None-Green Card Holder / Lawful Permanent Resident (LPR)Temporary Visa HolderVisa OverstayUndocumented / Entered Without InspectionAsylee / RefugeePreviously Ordered DeportedTemporary Protected Status (TPS)DACA / DREAMer StatusDeferred ActionUnknownOtherDate of Current Immigration StatusConviction History County of Case -None-Bronx CountyKings County (Brooklyn)New York County (Manhattan)Queens CountyRichmond County (Staten Island)Other non-NYSOther NYSDocket NumberOffense Commission DateCrim Trial Disposition -None-Pled GuiltyPled Guilty + YOConvicted at TrialACDDismissalNot Guilty by Reason of Mental Disease/DefectNolo ContendereOtherUnknownStatute/Subsection of ConvictionPlea/conviction DateSentenceSentence DateUpload a FileFile(s) size limit is 20MB.