Yes

No

Do you have any temporary or permanent civil protection orders or restraining orders issued against you?

Are you currently married?

Yes

No

Have you been married before?

Yes

No

If ‘Yes’ please state the date and place of termination of your previous marriage/s, plus any addition relevant information.

Have you any Federal, State or local arrests or convictions for homicide, murder, manslaughter, assault, battery, domestic violence, rape, sexual assault,  abusive sexual contact, sexual exploitation, incest, child abuse or neglect, torture, trafficking, peonage, holding hostage, involuntary servitude, slave trade, kidnapping, abduction, unlawful criminal restraint, false imprisonment, or stalking, solely, principally, or incidentally engaging in prostitution; a direct or indirect attempt to procure prostitutes or persons for the purpose of prostitution; or receiving, in whole or in part, of the proceeds of prostitution or offences relating to controlled substances or alcohol.

Yes

No

If you answered ‘Yes’ then please explain

Have you ever sponsored an alien with whom you were engaged or married?

Yes

No

Please check all places of residence in the US since you were 18 years old

Alabama

Alaska

Arizona

California

Arkansas

Indiana

Iowa

Kansas

Louisiana

Kentucky

Nebraska

Nevada

NewHampshire

New Mexico

New Jersey

South Carolina

South Dakota

Tennessee

Utah

Colorado

Maine

New York

Vermont

Texas

Connecticut

Maryland

North Carolina

Virginia

Delaware

Florida

Massachusetts

Michigan

North Dakota

Ohio

Washington

West Virginia

Georgia

Minnesota

Oklahoma

Wisconsin

Hawaii

Mississippi

Oregon

Wyoming

Idaho

Missouri

Pennsylvania

District of Columbia

Illinois

Montana

Rhode Island

U.S. Dependent Territories

Have you lived outside the US?

Yes

No

If ‘Yes’ then please explain.

You confirm that by submitting this form you declare that you have answered these questions truthfully and are aware that With Love From Voronezh is required to check your name against the database of sexual offenders http://www.nsopr.gov and will present the contents of this Personal Disclosure Form to the lady in her native language together with your initial introduction letter.

Full Name:

E-mail address:

Address: