Middle Name 
Last Name 
Date of Birth (DD/MM/YYYY) 
Signature 

PERSONAL DISCLOSURE STATEMENT 

This form is used to meet the requirement of IMBRA 2005 (HR03657). This information will be translated into 
Russian and provide to any lady that you wish to make contact with either via purchase of her contact 
information.

Please, print this page, fill in all required information below, date, sign and e-mail a scanned copy to admin@marriageagency-nataly.net   

First Name 

(1) Do you have any temporary or permanent civil protection order or restraining order issued against you?  
      o Yes o  No   If Yes, Please provide details of such order including date, city and  state 
______________________________________________________________________________________________ 
 
______________________________________________________________________________________________ 
 
(2) Any arrest or conviction of the client or person 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, stalking, or any similar activity in  violation of Federal, State or local criminal law?  
o Yes o  No  If Yes so please provide details 
______________________________________________________________________________________________ 
 
______________________________________________________________________________________________ 
 
(3)  Have you ever had any Federal, State, or local arrest or conviction for offenses related to controlled substances or 
alcohol?   o  Yes    o  No If Yes so please provide details 
______________________________________________________________________________________________ 
 
______________________________________________________________________________________________ 
 
(4) Are you currently married?   o  Yes   o  No 
 
(5) Have you ever been married?  o  Yes   o  No  If Yes pleases indicate how many times you have been married, when 
and  where you were previously married, when and where previous marriage's)  were dissolved? 
______________________________________________________________________________________________ 
 
______________________________________________________________________________________________ 

(6)   Have you previously sponsored an alien fiancée to whom you were engaged or married?  o Yes o No  If Yes please 
provide details 
__________________________________________________________________________________________ 
          
(7)   Do you have any children who are under the age of 18?     o  Yes  o  No    If yes please list how many  First Names 
and ages of Children_______________________________________________________________________________ 
 
______________________________________________________________________________________________ 
          
(8)  List all States and countries in which you have resided since the age of 18 : 
______________________________________________________________________________________________ 
 
______________________________________________________________________________________________ 
      
(9)  Are there any records on your name here: http://www.nsopr.gov  ?   o Yes     o  No 

Date (DD/MM/YYYY)