3 4 5 9  Lawrenceville - Suwanee  Rd., Suite A,  Suwanee ,  Georgia

Tel: (770) 271-5244 ● Toll Free:  (888) 768-7252 ● Fax: (770) 271-5604 ● Cornel@PotraLawFirm.com ● www.potralawfirm.com

Attorneys:  Cornel Potra – Admitted: Georgia & Washington  ●  Kristina F Potra – Admitted: Georgia

This questionnaire is for the exclusive use of Potra Law Firm.  Please answer all the questions.  Do not leave any questions unanswered.  If you do not have an answer to a question, please insert “N/A”.  It is your responsibility to provide true and accurate information, as well as the evidentiary documents requested. 

 

This Document Is For The Attorney’s Office Use Only

 

  

QUESTIONNAIRE FOR THE DS-230 I FORM
 

Personal Information

1. Full Name

a. Family name

 b. First name

c. Middle name

 

2. Other name(s) used:

   a. Maiden name

   b. Name(s) used from prior marriage(s)

 

 

3. Date of birth month/day/year

4. Age

5. Place of birth City/State/Country

6. Nationality

7. Gender

8. Marital status

9. Number of marriages including the current one

 

 

10. Give the permanent address in the U.S. where you intend to live:

   a. Street number

   b. City

   c. State

   d. Zip code

   e. Name of the person currently living at this address

 

11. The address in the U.S. where you want your Permanent Resident Card mailed to, if different than above:

 

   a. Street number

   b. City

   c. State

   d. Zip code

 

12. Current occupation

 
 

13. Current address:

 

   a. Street  number

   b. City

   c. State/Province

   d. Zip code

   e. Country

   f.  Phone number

   

14. Information about your spouse

 

   a. Family Name (maiden name for females)

   b. First Name

   c. Middle Name

   d. Date of Birth month/day/year

   e. Place of Birth City/State/Country

   f. Spouse’s address, if different than your own:

  

      Street  number

      City

      State/Province

      Zip code

      Country

   g. Spouse’s occupation

   h. Date of marriage month/day/year

   

15. Information about your father

 

   a. Family Name

   b. First Name

   c. Middle Name

   d. Date of Birth month/day/year

   e. Place of Birth City/State/Country

   f.  Father's current  address:

  

       Street number

       City

       State/Province

       Zip code

       Country

   g. Deceased

   

16. Information about your mother

 

   a. Maiden Name

   b. First Name

   c. Middle Name

   d. Date of Birth month/day/year

   e. Place of Birth City/State/Country

   f.  Mother's current  address:

  

       Street number

       City

       State/Province

       Zip code

       Country

   g. Deceased

   

17. Information about your children

 

 

a. Family Name

b. First Name

c. Middle Name

d. Date  of birth

e. Place of Birth

f. Children's current addresses, if different from your own

month/day/year

City/State/Country

 Street/City/State/ZipCode/Country

 1.

 

 2.

 

 3.

 

 4.

 

 5.

 

 6.

 

 7.

 

 8.