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Contact Information
Legal First Name
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Legal Middle Name
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Legal Last Name
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Preferred Name
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Email
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Cell Phone
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WhatsApp Number
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Street Address
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City
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Zip
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Demographic Information
Birthday
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Gender
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Birth Country
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso (UVolta)
Burma
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
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Croatia
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Cyprus
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Estonia
Ethiopia
Falkland Islands (Islas Malvinas)
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, Republic of South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
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Nepal
Netherlands
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Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
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Papua New Guinea
Paraguay
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Poland
Portugal
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Qatar
Romania
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Samoa
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Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka (Ceylon)
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
São Tomé and Príncipe
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
Union of Soviet Socialist Republics
United Arab Emirates
United Kingdon
United States of America
Unknown
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
West Bank
Yemen
Yugoslavia
Zambia
Zimbabwe
Language Spoken at Home
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Zotung - Chin dialect from Rezua in Maputi Township
Acehnese
Acholi
Afar
Afrikaans
Akan
Albanian
Aluru
Amharic
Ankole
Anuak
Arabic
Arabic, Moroccan Spoken
Arabic, Sudanese Spoken
Arabic, Tunisian Spoken
Arakan - Major dialect Rakhine and Arkan States
Armenian
Assamese
Assyrian
Azerbaijani (Azeri)
Azerbaijani, North
Bambara
Bangla
Banjuni
Bantu
Barawan
Bargo
Bari
Bassa
Behdini
Belarusan
Bemba
Bembe
Benadir
Bengali
Berti
Bilen
Bulgarian
Burmese
Cebuano
Central Igbo
Chaldean
Chechen
Chichiwa
Chin
Chin - Dai
Chin - Kanpelet
Chin Lai
Chin-Falam
Chin-Khumi
Chin-Matu
Chin-Mindat
Chin-Mizo
Chin-Senthang
Chin-Siyin
Chin-Zaniat
Chin-Zokhua
Chinese
Chinese, Cantonese
Chinese, Jinyu
Chinese, Mandarin
Chinese, Yue
Chittagonian
Circassian (Syrian Spoken)
Creole
Creole (Sierra Leonean Creole English)
Creole, Haitian Creole French
Croation
Czech
Dadjo
Danish
Dari
Daroud
Dawei/Tavoy
Didinga
Dinka
Dutch
Dzongka
East Pwo
English
Erenga
Ewe
Falam
Farsi
Farsi, Eastern
Farsi, Western
Filipino
Foor
French
Fula
Fulani
Fulbe
Fur
Gagauz
Garifuna
Georgian
German, Standard
Gio
Greek
Gujarati
Hakha - Chin Burmese dialect
Hausa
Hazaragi
Hebrew
Hema
Hindi
Hmong
Hungarian
Indonesian
Italian
Japanese
Jarai
Javanese
Kaba
Kachin - Jingpaw
Kachin - Lisu
Kachin - Major dialect from Kachin State
Kachin - Rawang
Kakwa
Kannada
Karen
Karenni - Kayah
Karenni - Kayan
Kayah
Kazakh
Khmer
Kibembe
Kifulero
Kiganda
Kikongo
Kikuyu
Kinande
Kinyabwisha
Kinyamulenge
Kinyarwanda
Kirundi
Kishi
Kissi
Kiswahili
Kitabwa
Kivira
Kizigua
Korean
Kpelle
Krio
Kuku
Kunama
Kurdi
Kurmanji
Kwakwa
Kyrgyz
Lai - Major Chin dialect from Thantalang and Hakha
Laotian
Lari
Latvian
Lautu - Chin dialect from Thantlang and Matupi Townships
Liberian English
Lingala
Lithuanian
Lori
Luba Kasai
Luba-Kasai
Luganda
Mabani
Macedonian
Madi
Maimai
Malagasy
Malay
Mandean
Mandingo
Mano
Mara - Chin dialect from Thantalang and Matupi Townships
Mararit
Mashi
Massalit
Matu
Mayan
Mizo (Lushai)
Mon
Mongolian
Monokutuba
Moro
Napoletano-Calabrese
Nepali
Ngawn
Nuba
Nuer
Nuristani
Oromo (Southern)
Oromo, West Central
Other Minor Languages
Pakhtu
Panjabi
Panjabi, Eastern
Panjabi, Western
Pashai
Pashto
Pashto (Central)
Pashto, Northern
Pashto, Southern
Persian
Polish
Portuguese
Poullar
Punjabi
Pwo Karen
Quiche, West Central
Rahaweyn
Rakhine
Rawang
Rega Lega
Rohingya
Romanian
Runyankore
Russian
Rwanda
Saho
Sango
Saraiki
Serbian
Serbo-Croatian
Sesotho
Setswana
Sgaw Karen
Shan - Major dialect from Shan State
Shilluk
Shona
Sidamo
Sign Language
Sindhi
Sinhala
Siryac
Siyin
Slovak
Slovenian
Somali
Somrai/Sibine
Songhay, Humburi Senni
Sorani
Spanish
Sunda
Swahili
Swedish
Tagalog
Tajiki
Tama / Damut
Tamil
Tatar
Tedim - Chin dialect from Thantalang and Matupi Townships
Telugu
Tembo
Temne
Thai
Tigray
Tigre
Tigrigwa
Tigrinya
Tshiluba
Tunjur
Turk,Iranian
Turkish
Turkman
Uduk
Ukrainian
Unknown
Urdu
Urhobo
Uzbek
Vietnamese
Wolof
Yakoma
Yoruba
Zaghawa
Zo - Chin dialect
Zomi
Zophei - Chin dialect from Thantlang Township
Zulu
Date of Entry into US
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Primary Support Person
Primary Support Person/US Tie First Name
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Primary Support Person/US Tie Last Name
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Primary Support Person/US Tie Cell Phone
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Services Needed
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