HOW TO APPLY FOR ASYLUM - The Florence Project

Documentation Request Form
Please fill out all sections and write neatly. Send this form to one of the organizations listed on the
Organizations page. It will be helpful if you also send your asylum application (I-589), letters or forms
that explain your case. These are for internal use only to help document your asylum claim. This
information will not be shared with any other organization, DHS or any other governmental agency
without your prior written consent.
NAME:___________________________________________ A#:__________________________________
ADDRESS:__(address where you want the information sent)________________________________________________
CITY:_________________________ STATE:________________ZIP CODE: _______________________
TODAY’S DATE:____________________DATE OF YOUR HEARING/APPEAL:___________________
PLEASE LIST ALL OF THE ORGANIZATIONS YOU HAVE CONTACTED:______________________
_______________________________________________________________________________________
YOUR CITY/TOWN, STATE, AND COUNTRY OF ORIGIN:____________________________________
YEAR OF ARRIVAL IN UNITED STATES: _________________________________________________
PLEASE CIRCLE AND ANSWER ALL THAT APPLY:
1. ARE YOU OR WERE YOU A MEMBER OF A PERSECUTED POLITICAL ORGANIZATION YES NO
IF YES, PLEASE LIST ORGANIZATION:___________________________________________________________
2. ARE YOU OR WERE YOU A MEMBER OF A PERSECUTED TRADE UNION YES NO
IF YES, PLEASE LIST NAME OF ORGANIZATION:_________________________________________________
3. ARE YOU OR WERE YOU A MEMBER OF A PERSECUTED CHURCH OR RELIGION YES NO
IF YES, PLEASE LIST RELIGION AND/OR CHURCH:________________________________________________
4. ARE YOU OR WERE YOU A MEMBER OF A PERSECUTED ETHNIC MINORITY YES NO
IF YES, PLEASE LIST ETHNICITY: _______________________________________________________________
5. IS YOUR CLAIM BASED ON SEXUAL ORIENTATION (BECAUSE YOU ARE GAY, LESBIAN, BISEXUAL,
OR TRANSGENDERED) YES NO
6. WERE YOU PERSECUTED BY THE GOVERNMENT OR GOVERNMENT MEMBERS YES NO
IF YES, LIST GROUP:___________________________________________________________________________
7. WERE YOU PERSECUTED BY AN ORGANIZATION/PERSONS OUTSIDE GOVERNMENT YES NO
IF YES, LIST GROUP:___________________________________________________________________________
8. IS YOUR CLAIM BASED ON PERSECUTION BECAUSE OF YOUR GENDER YES NO
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FIRRP- last update June 2007