Please fill out the information below to the best of your capability.

We would like to gather some information to better help those impacted by detention and deportation. This form will help us figure out how and who can best serve you. We are a group of community organizations providing many different services, we are not attorneys and do not provide legal advice.

Once you complete and submit this secure form, two copies will be sent, one to you and one to us. After you complete the form, we will review your information and reach out to you. This is a secure site and we will not share the information provided on this form with anyone outside of our organizations without your permission.

Please check out this website for several links to resources: http://searaids.org/resources/

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Contact Information

First Name Last Name

Date of Birth

Street Address (Optional)

Postal Code City State/Province

Email Phone

Remember me so that I can use FastAction next time.

(Optional)

Additional Information

Which organization referred you to this form?

Please Provide your A Number.

Please provide your ethnicity.

Which Country is I.C.E trying to send you to?

When did you arrive in the U.S.?

Did you or do you have a family member that was connected to a US-backed military during the Southeast Asian wars?

Yes

I Don't Know

For example, were you or your parents/grandparents connected with the Royal Lao Army, the CIA's Special Guerilla Unit (SGU), the Army of the Republic of Vietnam (ARVN) connected to reeducation camps, or the Khmer National Armed Forces with general Lon Nol?

If you answered yes to being involved or having a family member involved in the U.S.-back military in Southeast Asia , please explain (Optional)

Have You Received a Removal Order?

If you answered yes, when (YEAR) and where (STATE)? (Optional)

Describe your immigration detention history. Where were you detained and for how long? If you have never been detained by I.C.E please enter N/A.

Describe your immigration court history. Did you have an immigration attorney or did you represent yourself? In immigration court, did you try to fight your case by applying for asylum or did you sign an order for removal? (Optional)

When is your next I.C.E check-in?

If you have an immigration attorney, please provide their name and firm. If you don't have an attorney but have consulted with one, please provide their name, firm and what they said. If you haven't spoken to an attorney at all, please enter N/A.

Do you have a criminal conviction?

If Yes, did you take a plea deal or go to trial?

Did you have an attorney in criminal court?

In what state (which states) were your conviction(s)?

Were you advised of immigration consequences?

Please provide DETAILED information about your crime(s) - Charges, level of conviction (Month/Year & County, State), jail/prison time (where - City, State) and length of probation.

FOR EXAMPLE, an individual could write: When I was 18 years old, I got convicted of 2nd-degree Robbery, a felony on 02/2000 in Ramsey County, MN I spent 10 days in jail and 2 years in prison at Lino Lakes, MN; I was released on 03/2001 and received 6 months probation. I was also convicted of domestic violence, a gross misdemeanor on 09/2009 in Scott County, MN I spent 3 days in jail and 1 year in prison at Rush City, MN; I was released on 07/2010 and received 1-year probation. I was convicted of a small amount of marijuana, a misdemeanor on 04/2013 in Dakota County, I spent 2 days in jail and received no probation.

Provide your crimes and charges below:

Please describe the harm to you, your family, and the community in the case of your deportation.

Please be SPECIFIC and DETAILED as possible. For instance, if you have children, PROVIDE information about your children - the number of children and their ages. If you care for your elderly ill parent, please indicate which parent, whether or not they live with you, their age and illness. FOR EXAMPLE, an individual could write - I got legally married in 2002 and have 2 boys (2, 8) and 2 daughters (4, 6). My oldest son has down syndrome and requires special care. I also provide health insurance to all my family members and contribute significantly to household bills. I also care for my 76 year old elderly father who has lost functioning in parts of their body due to stroke.

Provide the harms your deportation will cause below:

Anything else that would be helpful for us to know? (Optional)