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PCR referral form
Assigned

-None-
Genia
Jane
Marie
Patrick
Ryan
Other
Unassigned
Natalia
Nabilah
Lee

Is this ILS?

Yes
No

Type

-None-
Immigration
State Criminal – Trial Level
State Criminal – Appellate Level
Family
Federal Criminal – Trial Level
Federal Criminal – Appellate Level
PCR
Other

Inquiry Source

-None-
Hotline Call
Webform
Email
Other Phone Call
Other

Intake Received Via

-None-
Hotline call
Webform
Email
Other phone call
Other

Attorney First Name*
Attorney Last Name*
Email*
Phone*
Organization/Firm Name
Client First Name*
Client Last Name*
Immigration Contacts*

Contemplating USCIS application/travel
Informal contact (in-custody interview, detainer, etc.)
Pending USCIS application
Currently in removal proceedings
Prior removal proceedings
Prior deportation order
Previously removed from the US
On an Order of Supervision
None of the above
Unknown
Other

Detention*

-None-
Criminal custody – remand/sentence
Criminal custody – bail set
Criminal custody – ICE detainer
ICE custody – no bond
ICE custody – bond set
Not in custody
ICE
Federal
No
State
Rikers

Custody Location
Client Current Immigration Status*

-None-
Green Card Holder / Lawful Permanent Resident (LPR)
Temporary Visa Holder
Visa Overstay
Undocumented / Entered Without Inspection
Asylee / Refugee
Previously Ordered Deported
Temporary Protected Status (TPS)
DACA / DREAMer Status
Deferred Action
Unknown
Other

Current Imm. Status (if Other)
Date of Current Immigration Status
Client Date of Entry
Client Manner of Entry

-None-
Green Card / Lawful Permanent Resident Status
Entry Without Inspection
Temporary Visa
Refugee / Asylee
Other
Unknown

Manner of Entry (if Other)
Last Exit/Entry to U.S.
Client Date of Birth
Client Country of Birth

-None-
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Democratic Rep)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland (Republic)
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Hong Kong
West Bank
Puerto Rico
Democratic Republic of the Congo
Bosnia and Herzegovina
Netherlands Antilles
Ireland
Aruba
British Virgin Islands
Burkina Faso
USA
Russia
South Korea
Myanmar
Bosnia-Herzegovina
Saint Kitts and Nevis
Saint Lucia
Cote d'Ivoire
Saint Vincent and the Grenadines
Viet Nam
Antigua and Barbuda
Mexico Micronesia Federated States of
Trinidad and Tobago

Alien Number
County of Case (Select Non-NY if applicable)*

-None-
Bronx County
Kings County (Brooklyn)
New York County (Manhattan)
Queens County
Richmond County (Staten Island)
Other non-NYS
Other NYS

Crim Trial Docket Number*
Statute/Subsection of Conviction*
Level of Charge*

-None-
Felony
Misdemeanor
Violation
Other
Unknown

Crim Trial Disposition*

-None-
Pled Guilty
Pled Guilty + YO
Convicted at Trial
ACD
Dismissal
Not Guilty by Reason of Mental Disease/Defect
Nolo Contendere
Other
Unknown

Offense Commission Date*
Plea/conviction Date*
Sentence Date*
Sentence*
If resentenced, new sentence
Represented By*
Prior 440 Motion Filed?
PCR Must-File Date
Reason for Filing Deadline*Help
Conviction History*
Conviction Imm Consequences*Help
Proposed Alternate Dispositions w/ Consequences*
Legal Basis for PCR Relief*Help
Equities*
Upload a File

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