Building One Community -

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Immigration Legal Services Intake Form

All information provided on this form is confidential and for B1C use only. There is a $50.00 fee for an initial consultation, unless waived. Payment is due at the time of scheduling.

We also update our WhatsApp Status regularly to inform about our upcoming programs and events and other community announcements. Please save our B1C outreach number (475) 333-9216 in your contacts to view those WhatsApp Status updates.

Have you been to Building One Community (B1C) before?

Yes

B1C Number (If known)

How did you hear about B1C?*

Your Name*

First Name Middle Name Last Name

Second Last Name

Your Address*

Street and Apartment City State ZIP Code

Mobile Phone*

We use SMS to inform you of our upcoming programs and events. Message and data rates may apply. Please check the box below If you DO NOT want to receive marketing SMS messages.

Unsubscribe from marketing SMS communication

I DO NOT want to receive marketing text messages from Building One Community.

Other Phone

Your Email

Birthday*

Gender*

Emergency Contact

Name

First Name Last Name

Phone

Relationship

Further information about you

Ethnicity*

Race*

What is your preferred language?*

What country were you born in?*

Year arrived in the US*

Year arrived in Fairfield or Westchester County*

Education Completed*

Employment Status*

Town of Employment (Please select all that apply.)*

Stamford

Greenwich

New Canaan

Darien

Norwalk

Bridgeport

Westport

Other

Marital Status

Information about the Beneficiary (the person who needs legal immigration help)

Are you inquiring about your own immigration situation (you are the beneficiary) or for somebody else?*

my own immigration situation (I am the beneficiary)

another beneficiary (they are the beneficiary)

Beneficiary Name

First Name Middle Name Last Name

Second Last Name

Beneficiary Address

Street and Apartment City State / Province / Region ZIP / Postal Code Country

Beneficiary's Mobile Phone

Beneficiary's Date of Birth

Beneficiary's Country of Birth

Beneficiary's Email

Beneficiary's Gender

Beneficiary's Marital Status

Is the Beneficiary currently in the United States?

yes

How did the Beneficiary enter the United States?*

Crossed U.S.-Mexico land border

Port of entry, such as an airport

Don't know

If the beneficiary crossed the U.S.-Mexico land border*

they were apprehended by immigration officials after crossing the border.

they presented themselves to immigration officials for asylum.

they had no contact with immigration officials.

Beneficiary's Current Immigration Status*

How many times has Beneficiary entered the U.S.?*

Beneficiary's Alien Registration Number

Beneficiary's Date of FIRST Entry to U.S.

Beneficiary's Date of LAST Entry to U.S.

Has the beneficiary ever been in immigration court?*

Yes

Don't know

When was the person last in Immigration Court ?

When is the next court hearing scheduled for?

Has the person ever missed an Immigration Court hearing?*

Yes

Don't know

When was the missed Immigration Court hearing?

Has the beneficiary ever filed any immigration form?*

Yes

Don't know

Has the beneficiary ever been arrested?*

Yes

Don't know

Has the beneficiary ever received any notices or papers from Customs & Border Patrol, USCIS, ICE, or Immigration Court?*

Yes

Don't know

Has the beneficiary ever been the victim of domestic violence or abuse by a spouse, partner, or other family member?*

Yes

Don't know

Has the beneficiary ever been the victim of a crime in the U.S.?*

Yes

Don't know

Does the beneficiary have fear of returning to their home country?*

Yes

Don't know

Information about the Beneficiary's Spouse

Name of Spouse

First Name Middle Name Last Name

Spouse's Date of Birth

Spouse's Place of Birth (City, Country)

Date of Marriage

Does the Beneficiary have children?

Yes

Information about the Beneficiary's Children

Child 1: Name

First Name Middle Name Last Name

Child 1: Date of Birth

Child 1: Place of Birth (City, Country)

Child 2: Name

First Name Middle Name Last Name

Child 2: Date of Birth

Child 2: Place of Birth (City, Country)

Child 3: Name

First Name Middle Name Last Name

Child 3: Date of Birth

Child 3: Place of Birth (City, Country)

Add more children?

Yes

Child 4: Name

First Name Middle Name Last Name

Child 4: Date of Birth

Child 4: Place of Birth (City, Country)

Child 5: Name

First Name Middle Name Last Name

Child 5: Date of Birth

Child 5: Place of Birth (City, Country)

Child 6: Name

First Name Middle Name Last Name

Child 6: Date of Birth

Child 6: Place of Birth (City, Country)

Section Break

FOR INTERNAL USE ONLY

Staff members, please provide your name if you helped fill out this form.

Staff Member Name

First Last

Name

This field is for validation purposes and should be left unchanged.

Building One Community is a 501(c)(3) nonprofit organization. Contributions are tax deductible to the extent allowed by law.

Stay in touch:

NEWSLETTERS

Building One Community is a 501(c)(3) nonprofit organization. Contributions are tax deductible to the extent allowed by law.

Stay in touch:

NEWSLETTERS

Immigration Legal Services Intake Form

Emergency Contact

Further information about you

Information about the Beneficiary (the person who needs legal immigration help)

Information about the Beneficiary's Spouse

Information about the Beneficiary's Children

Section Break

FOR INTERNAL USE ONLY

• Annual Report 2022

• Form 990

• Audited Financial Statements 2022

Stay in touch:

• Annual Report 2023

• Form 990

• Audited Financial Statements 2023

Stay in touch: