Public Charge Immigration Questionnaire

Full Name

First NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Household Size (including yourself)

List all household members and their relationship to you

Employment Status

Total Annual Household Income (in USD)

Do you or any household member receive any public benefits?

If yes, please list all public benefits received (e.g., SNAP, Medicaid, housing assistance, SSI, TANF, etc.)

Do you have health insurance?

Highest Level of Education Completed

List any significant assets (e.g., savings, property, vehicles, investments)

List any significant debts or liabilities