U Visa Victim Intake Document
Personal Information
Full Name
Other Names Used
Date of Birth
Country of Birth
Current Address
Phone Number
Email Address
Immigration Information
Immigration Status
Date of Entry to U.S.
Manner of Entry (if known)
Victimization Details
Type of Crime
Date(s) of Crime
Location of Crime
Brief Description of Incident
Did you report to police/law enforcement?
Agency Name (if reported)
Officer's Name/Badge Number (if known)
Family Information
List Immediate Family Members (Name, DOB, Relationship, Country of Residence)
Attorney/Advocate Information
Attorney/Advocate Name (if any)
Contact Information