Intake Form – Miami-Dade Assembly

New American
Intake Form

If you prefer to have someone else prepare your documents for you, and depending on the option you chose in Correct Your Status Step 5, the following levels of service are currently available:

1779 One-pager

Level 1: $50 Editing, Recording, and Publishing your paperwork
Level 2: $115 Editing, Recording, and Publishing your paperwork and mailing out your Notices to the IRS and Internal Revenue Service (they are different companies)
- Postage included for two (2) Notices

928 Package

Level 1: $200 Editing, Recording, and Publishing your paperwork
Level 2: $384 Editing, Recording, and Publishing your paperwork and mailing out your Notices to Secretaries of State, IRS, etc.
- Postage included for five (5) Notices

You will receive all original paperwork and receipts.

It is very important that the information is as complete and accurate as possible.

When entering your information

Only use proper casing (upper and lower case words)
Do not add all caps (THIS IS ALL CAPS)
Spell out words, no abbreviations please (FL should be spelled out Florida, Ave. is Avenue, St. is Street, etc.)
Check your spelling and dates for accuracy

After submitting the intake form, send the following documents to the [email protected]:

Your Birth Certificate or Naturalization Certificate “in-color” photocopy
Color copy of a government-issued ID card (Driver License, Passport Card, Passport Book, State-issued ID, etc.)

Service Level

Personal Information

Full Name *

Name Full Name on Birth Certificate *

Full Current Name *

List All Other "Legal" Names (by marriage, court action, divorce, etc.)

“Known by” names include nick names, pen names, stage names, abbreviations, etc. Also include business(s), social media handles if different than your name.

List All Known By Names

Street Address, include Apartment/Suite number *

City *

State *

Postal Code *

County *

Phone Number *

Email *

Birth Date *

Were you born in America?

If No, what country were you born in?

City where you were born *

County and state where you were born *

Are you former or active duty military?

Are you a Federal Employee?

Are you registered to vote?

Are you a Green Card immigrant?

If yes, will you be adopting Florida as your home state?

Are you an undocumented immigrant living in America for at least 7 years?

Power of Attorney Exception

If you would like someone to continue to have Power of Attorney, please enter their name, otherwise enter “N/A”.

Full Name *

Parental Information

Father‘s Full Name (if you don’t know it, enter "N/A") *

Mother’s Full Name On The Day You Were Born *

Mother’s Full Maiden Name *

If married but the following information is unknown, enter “don’t know”

If not married, enter “unmarried”

Wedding Date *

Wedding City, State, and Country *

Children

If you have children under 21 years of age and you would like to have a Record of Life (Baby Deed) created for each of them, please provide the following information:

Child number one:

Full Name

Date and Time of Birth

Gender

City of Birth

State of Birth

Mother’s Full Name

Mother’s Date of Birth

Mother’s County, State / Country of Birth

Father’s Full Name

Father’s Date of Birth

Father’s County, State / Country of Birth

This baby is (first/second/etc.) living child and (first/second/etc.) son/daughter

Child number two:

Full Name

Date and Time of Birth

Gender

City of Birth

State of Birth

Mother’s Full Name

Mother’s Date of Birth

Mother’s County, State / Country of Birth

Father’s Full Name

Father’s Date of Birth

Father’s Couny, State / Country of Birth

This baby is (first/second/etc.) living child and (first/second/etc.) son/daughter

Child number three:

Full Name

Date and Time of Birth

Gender

City of Birth

State of Birth

Mother’s Full Name

Mother’s Date of Birth

Mother’s County, State / Country of Birth

Father’s Full Name

Father’s Date of Birth

Father’s County, State / County of Birth

This baby is (first/second/etc.) living child and (first/second/etc.) son/daughter

Copy the following list in the field below and add your information for each additional child:

Child number four:
Full Name:Date and Time of Birth:
Gender:
City of Birth:
State of Birth:
Mother’s full name:
Mother’s Date of Birth:
Mother’s County, State/Country of Birth:
Father’s full name:
Father’s Date of Birth:
Father’s County, State/Country of Birth:
This baby is (first/second/etc.) living child and (first/second/etc.) son/daughter

Additional Children

New American

Service Level

Personal Information

Power of Attorney Exception

Parental Information

Children