Test ILS intake form ILS Intake Form (1) "*" indicates required fields Immigration Legal Services Intake FormAll 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 No B1C Number (If known) How did you hear about B1C?*Another B1C VolunteerAnother organizationB1C PresentationB1C WebsiteChurchFamily MemberFriendNewspaperOutreach / FlyerSchoolSocial MediaWalk ByWhatsAppYour Name* First Name Middle Name Last Name Second Last Name Your Address* Street and Apartment City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 PhoneYour Email Birthday* MM slash DD slash YYYY Gender*MaleFemaleNon-binary genderPrefer not to answerEmergency ContactName First Name Last Name PhoneRelationshipAuntBrotherCousinDaughterFatherFriendHostMotherPartnerSisterSonSpouseUncleOtherFurther information about youEthnicity/ Race* Asian — For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc. Black or African American — For example, African American, Jamaican, Nigerian, Ethiopian, Somali, etc. Caribbean — For Example, Haitian. Hispanic or Latino — For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc. Middle Eastern or North American — For Example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc. White — For example, English, German, Irish, Italian, Polish, Scottish, etc. Other What is your preferred language?*EnglishSpanishIndigenous LanguageAmharicArabicArmenianBengaliBelarusianBulgarianCajunChineseCroatianCzechDanishDutchFinnishFormosanFrenchGermanGreekGujarathiHaitian CreoleHebrewHindi (urdu)HungarianIlocanoItalianJapaneseKoreanKruLithuanianMalayalamMiao (hmong)Mon-khmer (cambodian)NavahoNorwegianPanjabiPennsylvania DutchPersianPolishPortugueseRumanianRussianSamoanSerbocroatianSlovakSwedishSyriacTagalogThai (laotian)TurkishUkrainianVietnameseYiddishUnknownWhat country were you born in?*GuatemalaEcuadorHondurasPeruMexicoVenezuelaColombiaUnited StatesUruguayPuerto RicoParaguayDominican RepublicEl SalvadorArgentinaBoliviaChileAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurma (Myanmar)BurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChinaComorosCongoCongo, Democratic Republic ofCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaEast TimorEgyptEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuineaGuinea-BissauGuyanaHaitiHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUzbekistanVanuatuVatican CityVietnamYemenZambiaZimbabweYear arrived in the US* Year arrived in Fairfield or Westchester County* Education Completed*1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeGEDBachelors DegreeSome CollegeGraduate DegreeNo SchoolingN/AEmployment Status*Full-timePart-timeSeasonallyHomemakerUnemployedTown of Employment (Please select all that apply.)* Stamford Greenwich New Canaan Darien Norwalk Bridgeport Westport Other Marital StatusNever MarriedMarriedDivorcedSeparatedWidowedCo-habitatingInformation 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Beneficiary's Mobile PhoneBeneficiary's Date of Birth MM slash DD slash YYYY Beneficiary's Country of BirthAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweBeneficiary's Email Beneficiary's GenderMaleFemaleBeneficiary's Marital StatusNever MarriedMarriedDivorcedSeparatedWidowedCo-habitatingIs the Beneficiary currently in the United States? yes no 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* US Citizen Permanent Resident Visa DACA TPS Other None How many times has Beneficiary entered the U.S.?* 0 1 2 3 or more Don’t know Beneficiary's Alien Registration Number Beneficiary's Date of FIRST Entry to U.S. MM slash DD slash YYYY Beneficiary's Date of LAST Entry to U.S. MM slash DD slash YYYY Has the beneficiary ever been in immigration court?* Yes No Don’t know When was the person last in Immigration Court ? MM slash DD slash YYYY When is the next court hearing scheduled for? MM slash DD slash YYYY Has the person ever missed an Immigration Court hearing?* Yes No Don’t know When was the missed Immigration Court hearing? MM slash DD slash YYYY Has the beneficiary ever filed any immigration form?* Yes No Don’t know Has the beneficiary ever been arrested?* Yes No Don’t know Has the beneficiary ever received any notices or papers from Customs & Border Patrol, USCIS, ICE, or Immigration Court?* Yes No Don’t know Has the beneficiary ever been the victim of domestic violence or abuse by a spouse, partner, or other family member?* Yes No Don’t know Has the beneficiary ever been the victim of a crime in the U.S.?* Yes No Don’t know Does the beneficiary have fear of returning to their home country?* Yes No Don’t know Information about the Beneficiary's SpouseName of Spouse First Name Middle Name Last Name Spouse's Date of Birth MM slash DD slash YYYY Spouse's Place of Birth (City, Country) Date of Marriage MM slash DD slash YYYY Does the Beneficiary have children? Yes No Information about the Beneficiary's ChildrenChild 1: Name First Name Middle Name Last Name Child 1: Date of Birth MM slash DD slash YYYY Child 1: Place of Birth (City, Country) Child 2: Name First Name Middle Name Last Name Child 2: Date of Birth MM slash DD slash YYYY Child 2: Place of Birth (City, Country) Child 3: Name First Name Middle Name Last Name Child 3: Date of Birth MM slash DD slash YYYY 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 MM slash DD slash YYYY Child 4: Place of Birth (City, Country) Child 5: Name First Name Middle Name Last Name Child 5: Date of Birth MM slash DD slash YYYY Child 5: Place of Birth (City, Country) Child 6: Name First Name Middle Name Last Name Child 6: Date of Birth MM slash DD slash YYYY Child 6: Place of Birth (City, Country) Section BreakConsentINITIAL CONSULTATION AGREEMENTAt Building One Community (B1C), we take great professional satisfaction in providing you with information on your immigration matter by means of an Initial Consultation. All information provided by you during the consultation and this intake form will be held in strict confidence to the extent of the law. We can only provide an accurate analysis of your immigration matter based on truthful information.Please note that having an Initial Consultation does not mean that B1C will accept your case or represent you. We may be unable to accept a case for various reasons. If B1C accepts your case and agrees to represent you, you will be given a separate Client Engagement Letter that explains the terms of our representation. B1C does not represent you unless you and we sign a separate Engagement Letter.B1C carries out initial consultations remotely, by phone or videoconference. We will provide instructions prior to the scheduled consultation in order to make the consultation as productive as possible, and to maintain your information confidential.By clicking the box below, you indicate that you understand, acknowledge, and agree with the above, and promise to provide truthful information. You also understand that there is a $50.00 fee for this consultation, unless waived by B1C. Payment is due at the time of scheduling. We reserve the right to cancel the consultation if payment has not been received 48 hours prior to the scheduled date. If you need to reschedule a consultation, please do so at least 48 hours in advance. If you miss your consultation appointment, we may not be able to reschedule you promptly. I agree to this policy.FOR INTERNAL USE ONLYStaff members, please provide your name if you helped fill out this form.Staff Member Name First Last UntitledFirst ChoiceSecond ChoiceThird ChoiceUntitled First Choice Second Choice Third Choice CommentsThis field is for validation purposes and should be left unchanged. Δ
