Form I-687 Application for status as temporary resident under secti

Application for Status as a Temporary Resident Under Section 245A of the Immigration and Nationality Act

I-687 Draft 508 Rev 11-24-06

Application for Status as a Temporary Resident Under Section 245A of the Immigration and Nationality Act

OMB: 1615-0090

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OMB No. 1615-0090; Expires 03/31/07
Department of Homeland Security

U.S. Citizenship and Immigration Services

I-687, Application for Status as a
Temporary Resident Under Section 245A of the INA
Instructions

NOTE: Please carefully read all the instructions. The fee will not be refunded.

What Is the Purpose of This Form?
The original version of Form I-687 was designed for use
during the Immigration and Nationality Act (INA) section
245A legalization program of the 1986 Immigration Reform
and Control Act which ended in 1988. The form will now be
used to apply to U.S. Citizenship and Immigration Services
(USCIS) for benefits pursuant to the terms and conditions of
certain settlement agreements.
NOTE: USCIS is comprised of offices of the former
Immigration and Naturalization Service (INS).

1. Preparation of Application.

alien's period of authorized stay as a nonimmigrant
expired before such date through the passage of time or
the alien's unlawful status was known to the
government as of such date) and
B. He or she can establish that he or she has been

continuously physically present in the United States
since November 6, 1986 and through the date the
application is considered filed pursuant to the
settlement agreements.

3. Admissible as an Immigrant.
The alien must establish that he or she:

A separate application for each applicant must be typed or
printed legibly in black ink. The application must be
completed in full. If extra space is needed to answer any
item, attach a continuation sheet(s) and indicate the item
number.
If you send this application via the U. S. Postal Service,
mail it to the following address:

A. Is admissible to the United States as an immigrant,
except as otherwise provided under INA section 245A
(d)(2).
B. Has not been convicted of any felony or of three or
more misdemeanors committed in the United States;

DRAFT

U.S. Citizenship and Immigration Services
P.O. Box 805876
Chicago, IL 60680-4120

If you send this application through any other means, mail
it to the following address:
U.S. Citizenship and Immigration Services
427 S. LaSalle, 3rd Floor
Chicago, IL 60605-1029
If you do not sign your application or if you fail to submit
the appropriate fee according to the instructions below, we
will return your form. If your application is returned, no
further action will be taken. You would then need to
resubmit your application properly to renew processing.

C. Has not assisted in the persecution of any person or
persons on account of race, religion, nationality,
membership in a particular social group or political
opinion; and
D. Is registered or registering under the Military Selective
Service Act, if the alien is required to be so registered
under the Act.

4. Documents to Establish Identity.
You must submit proof of identity with your application.
The following are examples of the types of documents that
may serve to establish your identity:
A. Birth certificate, baptismal certificate or other evidence
of birth;

2. Eligibility.

B. National identification card from your country of
origin;

An alien may be eligible for Temporary Resident status if:

C. Passport;

A. He or she can establish that he or she entered the
United States before January 1, 1982, and that he or she
has resided continuously in the United States in an
unlawful status since such date and through the date the
application is considered filed pursuant to the
settlement agreements (in the case of an alien who
entered the United States as a nonimmigrant before
January 1, 1982, the alien must establish that the

D. Driver's license;
E. Identification card issued by a school or your State of
residence.
F. Military identification.

Form I-687 Instructions (11/13/06)Y

5.

Admissibility.

e. Utility bill receipts;

An applicant for temporary resident status pursuant to
section 245A of the Immigration and Nationality Act
(INA) must establish that he or she is admissible under
section 212(a) of the INA. In determining the
admissibility of an applicant, the provisions of sections
212(a)(6)(A) and 212(a)(7) of the INA shall not apply to
applicants for adjustment of status as a lawful temporary or
permanent resident under section 245A of the INA.

f. Installment loan records;

The following grounds of inadmissibility may not be
waived by the Secretary of Homeland Security:
(i) Section 212(a)(2)(A)(i)(I) (crimes involving moral
turpitude);
(ii) Section 212(a)(2)(A)(i)(II) (crimes involving
controlled substances, except for so much of such
paragraph as relates to a single offense of simple
possession of 30 grams or less of marijuana);
(iii) Section 2312(a)(2)(B) (multiple criminal convictions);
(iv) Section 212(a)(2)(C) (controlled substance traffickers);
(v) Section 212(a)(3) (security and related grounds); and

g. Church records, medical records;
h. Affidavits or declarations from third parties.
If you submit letters from landlords, the correspondence
must include the landlord's present address and the
beginning and ending dates of your residence. Letters
from employers, organizations or churches should be on
official stationery and include relevant dates, the
organization seal (if any) and the signer's name and title.
To evaluate the sufficiency of the applicant's proof of
residence, USCIS will take into account the passage of
time and attendant difficulties in obtaining corroborative
documentation of unlawful residence.

7. Additional Sheets.
If you do not have enough space to answer any particular
question on this form attach additional sheets and on each
sheet indicate your Name, Date of Birth, A-number (if
available) and Social Security number (if available) and
indicate the number of the question to which you are
replying.

8. Copies.

DRAFT

(vi) Section 212(a)(4) (public charge). Except this
prohibition does not apply to an alien who is or was an
aged, blind or disabled individual (as defined in section
1614(a)(1) of the Social Security Act. An alien is not
ineligible for adjustment of status due to being
inadmissible under section 212(a)(4) if the alien
demonstrates a history of employment in the United States
evidencing self-support without receipt of public cash
assistance. Special adjudication standards regarding public
charge contained in any settlement agreements apply.
All other grounds of inadmissibility may be waived by the
Secretary of Homeland Security. In order to seek such a
waiver, you must submit a Form I-690, Application for
Waiver of Grounds of Excludability.

6. Documents to Establish Residence.
Documents that may be submitted to prove continuity of
residence include but are not limited to:
a. Leases, rent receipts or deeds or other evidence of a
mortgage;
b. Birth certificates of children; born in the United States;
c. Employment, union or other business records;
d. Driver's license receipts or evidence of vehicle
registrations;

If these instructions tell you to submit a copy of a
particular document, you should send a copy. If there are
stamps, remarks, notations, etc., on the back of the original
document(s), please also provide a copy of the back of the
document(s).

If you choose to send an original document, you should
also send a copy and USCIS will return the original to
you. If you do not provide a copy along with the
original, USCIS will attach the original document to
your petition and it will not be returned to you.
There are times when USCIS must request an original
copy of a document. In that case, the original is generally
returned after it has been reviewed. If you are asked to
submit an original document, make a copy for yourself and
keep it in a safe place. For your personal records, we
advise you to keep copies of the petition and all of the
documents you submit to USCIS.
However, if you are interviewed, the original documents
must be presented whenever possible at that time except
for the following: official government records;
employment or employment related records maintained by
employers, unions or collective bargaining organizations;
medical records; school records maintained by a school or
school board; or other records maintained by a party other
than the applicant.

Form I-687 Instructions (11/13/06)Y Page 2

Copies of these records must be endorsed as true and
correct and must bear the signature and title of persons
authorized to act in their behalf. All certified copies of
documents become the property of USCIS. At the
discretion of a USCIS District Director, original
documents, even if accompanied by certified copies, may
be temporarily retained.

9. Foreign Language Documents.
Any document in a foreign language must be accompanied
by an English translation. The translator must certify that
he or she is competent to translate the foreign language
into English and that the translation is accurate.

10. Interview.
You may be required to be present for a personal interview
by a USCIS officer.

11. Biometric Services for Applicant's
Fingerprints, Photograph and Signature.
If you are between the ages of 14 and 79 years, you must
be fingerprinted as part of the USCIS biometric services
requirements. Biometric services may also include the
taking of your photograph and signature. After you have
filed this application, USCIS will notify you in writing on
Form I-797, Notice of Action, to call our National
Customer Service Center at 1-800-375-5283 to schedule
your biometric services appointment at a USCIS
Application Support Center in your area. If you fail to
appear for the biometric services appointment, your
application may be denied.

How to Check If the Fee Is Correct.
The fee on this form is current as of the edition date
appearing in the lower right corner of this page. However,
because USCIS fees change periodically, you can verify if
the fee is correct by following one of the steps below:
Visit our website at www.uscis.gov and scroll down to
"Forms and E-Filing" to check the appropriate fee, or
Review the Fee Schedule included in your form
package, if you called us to request the form, or
Telephone our National Customer Service Center at
1-800-375-5283 and ask for the fee information.
NOTE: If your petition or application requires a biometric
services fee for USCIS to take your fingerprints,
photograph or signature, use the same procedure above to
confirm the biometrics fee.

13. Employment Authorization.
Applicants seeking employment authorization must mail
Form I-765, Application for Employment Authorization,
to the appropriate address noted in these Instructions on
Page 1, Number 1. Provide the $180.00 fee with the
Form I-765 application.
An applicant previously issued a CSS or LULAC/Newman
employment authorization document may file a Form
I-765 one time without a fee. Such Form I-765 must be
submitted together with Form I-687 and worksheet.
Subsequent Forms I-765 must be submitted with fee.

DRAFT

12. What Is the Fee?
The fee is $255.00 (two hundred and fifty-five dollars) for
each application. The fee must be submitted when you
submit your application to USCIS.
If USCIS needs to take your fingerprints, photograph or
signature, you must also pay a biometric services fee of
$70.00 (seventy dollars).
Do not send cash. The fee must be submitted in the exact
amount. The fee cannot be refunded, regardless of the
action taken on the application. A separate check or
money order must be submitted for each application.
The check or money order should be made payable to the
Department of Homeland Security.
When preparing your check or money order, spell out
Department of Homeland Security. Do not use the initials
"USDHS" or "DHS."

14. Penalties for False Statements.
Whoever files an application for adjustment of status under
Section 245A of the Act and who knowingly and willfully
falsifies, misrepresents, conceals or covers up a material
fact or makes any false, fictitious, or fraudulent statements
or representations, or makes or uses any false writing or
document knowing the same to contain any false,
fictitious, or fraudulent statement or entry will be subject
to criminal prosecution and/or removal.

15. Our Authority for Collecting This Information.
The authority to prescribe this form is contained in the
"Immigration Reform and Control Act of 1986." The
information is necessary to determine whether a person is
eligible for the immigration benefit sought. Information
on race is requested in question Number 13 of the form
for statistical purposes only. You do not have to give this
information. All other questions must be answered. Failure
to do so may result in the denial of your application.

16. Confidentiality.
The information provided in this application is confidential
and may only be used as provided in INA Section 245A(c)
(5). The information provided is subject to verification by
USCIS.
Form I-687 Instructions (11/13/06)Y Page 3

17. USCIS Forms and Information.
To order USCIS forms, call our toll-free number at
1-800-870-3676. You can also get USCIS forms and
information on immigration laws, regulations and
procedures by telephoning our National Customer
Service Center at 1-800-375-5283 or visiting our internet
website at www.uscis.gov.

18. Use InfoPass for Appointments.
As an alternative to waiting in line for assistance at your
local USCIS office, you can now schedule an appointment
through our internet-based system, InfoPass. To access
the system, visit our website at www.uscis.gov. Use the
InfoPass appointment scheduler and follow the screen
prompts to set up your appointment. InfoPass generates an
electronic appointment notice that appears on the screen.
Print the notice and take it with you to your appointment.
The notice gives the time and date of your appointment,
along with the address of the USCIS office.

19. Paperwork Reduction Act Notice.
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a
collection of information unless it displays a currently
valid OMB control number. We try to create forms and
instructions that are accurate, can easily be understood and
that impose the least possible burden on you to provide us
with information. Often this is difficult because some
immigration laws are very complex.

DRAFT

The estimated average time to complete and file this
application is as follows: (1) 20 minutes to learn about the
law and form; (2) 20 minutes to complete the form; and (3)
30 minutes to assemble and file the application; for a total
estimated average time of 1 hour and 10 minutes per
application.
If you have comments regarding the accuracy of this
estimate, or suggestions for making this form simpler, you
may write to: U.S. Citizenship and Immigration Services,
Regulatory Management Division, 111 Massachusetts
Avenue, N.W., 3rd Flr., Suite 3008, Washington, DC
20529; OMB No. 1615-0090. Do not mail your
completed application to this address.

Form I-687 Instructions (11/13/06)Y Page 4

OMB No.1615-0090; Expires 03/31/07

I-687, Application for Status as a
Temporary Resident Under Section 245A of the INA

Department of Homeland Security
U.S. Citizenship and Immigration Services

Do not write in this block. For USCIS Use Only.
Action Block

Fee Stamp

Principal Applicant's A#

This applicant's A#

START HERE - Please type or print in capital letters in black ink. If you need more space, use a separate sheet(s) of paper.
1. I hereby apply for status as indicated by the block checked below.
A. Temporary Resident Status as an alien who illegally entered the U.S. prior to January 1, 1982.
B. Temporary Resident Status as an alien who entered the U.S. as a nonimmigrant prior to January 1, 1982 and whose authorized
stay expired before such date or whose unlawful status was known to the Government as of January 1, 1982.
2. Name
Family Name (in capital letters)

3. Date of Birth (mm/dd/yyyy)
Given Name

Middle Name

4. Other Names Used or Known by (Including maiden name, if married) 5. Telephone Numbers (Including Area Codes)

DRAFT
Home:

6. Home Address in the U.S.
In care of

Work:

U.S. Social Security #

Number and
Street
City

Apt. #
State

Zip
Code

7. Mailing Address in the U.S. (if different from address in Number 6.)
In care of
Number and
Street
City

Apt. #
State

Zip
Code

8. Last Address Outside the U.S.
Number and
Street
City

Apt. #
County, Province
or State

Country

9. Country of
Citizenship
10. Place of Birth
City or Town

County, Province
or State

Country
Form I-687 (11/13/06)Y

11. Marital Status
Now Married

Never Married

13. Race

12. Gender

Separated

Divorced

Asian or Pacific Islander

Black, not of Hispanic origin

Hispanic

White, not of Hispanic origin

Widowed
Other (specify below)

Male
Female

14. Have you previously applied for temporary residence as a Legalization applicant?
No

Yes

If Yes, give date, place of filing and final disposition, if known.

15. Do you have other records with USCIS (or the former INS)?
No

Yes

If Yes, give file numbers.

A#

Other

17. Manner of Entry

16. When did you first enter the U.S.?
(mm/dd/yyyy)

Without a visa

When did you begin living in the U.S.?

With a visa (visitor, student, etc.) specify:

(mm/dd/yyyy)
When did you last enter the U.S.?
(mm/dd/yyyy)
18. Place of last entry into U.S.
Port of Entry (City and State)
19. Mother's Name
(Give maiden name,
last name, first name)

Border - Not through a Port of Entry (State)

DRAFT

Living
Deceased (year)

20. Father's Name
Living
(Give last name, first
Deceased (year)
name)
If you were admitted as a nonimmigrant, please submit your I-94, Arrival/Departure record, and photocopies of any previous I-94
and complete Number 21 through 29. If not, leave blank and go to Number 30.
21. Passport Number

22. Country that issued Passport

24. Type of visa issued
(B-2, F-1, etc.)

25. Date visa issued (mm/ddyyyy) 26. Authorized stay in U.S.
Expired (mm/dd/yyyy)

23. Location where visa issued (City and Country)

27. Class of admission
(Student, visitor, etc.)

28. Did you violate your legal 29. Was your status violation known to the
status prior to January 1, 1982?
Government prior to January 1, 1982?
If Yes, how was your status violation
No
Yes
No
Yes known to the Government?
30. RESIDENCES IN THE UNITED STATES:
List all of your residences in the United States since your first entry, beginning with your present address.
If you need more space, attach an additional sheet(s). Indicate on the sheet(s) that the information refers to question Number 30.
Street Name and Number (Apt. No.)
City

State and
Zip Code

From
(mm/yy)

To
Present
(mm/yy)

Form I-687 (11/13/06)Y Page 2

30. RESIDENCES IN THE UNITED STATES, continued:

Street Name and Number (Apt. No.)
City

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

Street Name and Number (Apt. No.)
City
Street Name and Number (Apt. No.)

City
Street Name and Number (Apt. No.)
City
Street Name and Number (Apt. No.)
City
Street Name and Number (Apt. No.)
City

DRAFT
State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

State and
Zip Code

From
(mm/yy)

To
(mm/yy)

Street Name and Number (Apt. No.)
City
Street Name and Number (Apt. No.)
City
Street Name and Number (Apt. No.)
City
Street Name and Number (Apt. No.)
City
Street Name and Number (Apt. No.)
City

Form I-687 (11/13/06)Y Page 3

31. AFFILIATIONS OR ASSOCIATIONS: To which you belong or have belonged. Please list all affiliations or associations, clubs,
organizations, churches, unions, businesses, etc. to which you belong or have belonged. If you need more space, attach an additional
sheet(s). Indicate on the sheet(s) that the information refers to question Number 31.
Name of Organization

Location (City and State)

From (mm/yy) To (mm/yy)

32. ABSENCE FROM THE UNITED STATES SINCE ENTRY: List most recent absence first and then all previous absences dating
back to January 1, 1982. If you need more space, attach an additional sheet(s). Indicate on the sheet(s) that the information refers to
question Number 32.
Country

DRAFT
Purpose of Trip

From (mm/yy) To (mm/yy)

Form I-687 (11/13/06)Y Page 4

32. ABSENCES FROM THE UNITED STATES SINCE ENTRY, continued.
Country

Purpose of Trip

From (mm/yy) To (mm/yy)

33. EMPLOYMENT IN THE UNITED STATES SINCE ENTRY: Show most recent employment first and then all previous
employment dating back to January 1, 1982. If none, write "None." If you need more space, attach an additional sheet(s). Indicate on the sheet(s)

DRAFT

that the information refers to question Number 33.

Full Name of Employer
Street Name and Number (Apt. No.)
City

State and
Zip Code

Annual
Wage

Hourly
Wage

Occupation
From
(mm/yy)

To:
(mm/yy)

Full Name of Employer
Street Name and Number (Apt. No.)
City

State and
Zip Code

Annual
Wage

Hourly
Wage

Occupation
From
(mm/yy)

To:
(mm/yy)

Full Name of Employer
Street Name and Number (Apt. No.)
City

State and
Zip Code

Annual
Wage

Hourly
Wage

Occupation
From
(mm/yy)

To:
(mm/yy)
Form I-687 (11/13/06)Y Page 5

34.

I have registered under the Military Selective Service Act. My Selective Service Number is:
I am a male over the age of 17 and under the age of 26 required to register under the Military Selective Service Act and have not
done so. I wish to register at this time. My SSS Form 1 is attached.
I am a male born after 1959 and over the age of 26 and cannot now register.
I am exempt from Selective Service Registration either because I am a female or I was born before 1960.

35. Have you ever assisted in the persecution of any person or persons on account of race, religion, political
opinion, nationality or membership in a particular social group?

Yes

No

36. Have you ever been treated for a mental disorder, drug addiction or alcoholism?

Yes

No

37. Have you ever committed a crime or offense for which you were not arrested?
Have you ever been arrested, cited, charged, indicted, fired, or imprisoned for violating any law, including
misdemeanor vehicular offenses, or detained by any law enforcement officer (including USCIS or former
INS and military officers) for any reason?
Have you ever been charged with committing any crime or offense?
Have you ever been convicted of a crime or offense?
Have you ever been in jail or prison?
Have you ever been placed in an alternative sentencing or a rehabilitative program
(for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

c. knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the United States illegally?

Yes
Yes
Yes

No
No
No

d. illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of
any controlled substance?

Yes

No

Have you ever engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited membership or
funds for, or have you through any means ever assisted or provided any type of material support to any person or organization
that has ever engaged or conspired to engage in sabotage, kidnapping, political assassination, hijacking or any other form of
terrorist activity?
Yes

No

Have you ever received a suspended sentence, been placed on probation or been paroled?
Provide court records relating to any convictions, DMV records.
38. Have you, or a dependent member of your immediate family, ever received public assistance from any
source, including, but not limited to, the United States Government, any state, county, city or municipality?
If yes, provide the names(s) of the recipients(s) and U.S. Social Security number(s).

39. Have you ever:

DRAFT

a. within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities
in the future?
b. engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?

Do you intend to engage in the United States in:
a. espionage?
b. any activity a purpose of which is opposition to, or the control or overthrow of, the government of the United
States, by force, violence or other unlawful means?

Yes

No

Yes

No

Yes
Yes

No
No

Did you, during the period from March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany
or any organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist or
otherwise participate in the persecution of any person because of race, religion, national origin or political opinion?
Yes

No

Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of any
person because of race, religion, nationality, ethnic origin or political opinion?

Yes

No

Have you ever been deported from the United States, or removed from the United States at government expense,
excluded within the past year, or are you now in exclusion, deportation, removal or recision proceedings?

Yes

No

Are you under a final order of civil penalty for violating section 274C of the Immigration and Nationality Act for use of
fraudulent documents or have you, by fraud or willful misrepresentation of a material fact, ever sought to procure, or
procured, a visa, other documentation, entry into the United States or any immigration benefit?

Yes

No

c. any activity to violate or evade any law prohibiting the export from the United States of goods, technology or
sensitive information?
Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?

Form I-687 (11/13/06)Y Page 6

Have you ever left the United States to avoid being drafted into the United States Armed Forces?

Yes

No

Have you ever been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement
and have not yet complied with that requirement or obtained a waiver?

Yes

No

Are you now withholding custody of a United States citizen child outside the United States from a person granted
custody of the child?

Yes

No

Do you plan to practice polygamy in the United States?

Yes

No

40. If your native alphabet is in other than Roman letters, write your name in your native alphabet.

41. Language of your native alphabet.
42. Signature and Certification of Applicant.
I CERTIFY,under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. I hereby
consent and authorize the U.S. Citizenship and Immigration Services to verify the information provided and to conduct police, welfare and
other record checks pertinent to this application.

Date

Signature

43. Signature of person preparing form, if other than applicant.
I declare under penalty of perjury that I prepared this application at the request of the above person.
The answers provided are based on information of which I have personal knowledge and/or were provided to me by the above named
person in response to the exact questions contained on this form.

Signature

DRAFT
Date

Print Name
Address

Telephone number with area code

U.S. Citizenship and Immigration Services Use Only
44. Recommendation: Temporary Residence

Approved

Denied

45. Recommendation: Waiver of Inadmissibility under Section 212(a)

Approved

46. Class of Admission

47. Place of Adjustment

48. Date of Adjustment

49. Recommended by (Print Name and Title)

50. ID Number

51. Date

52. Final Action: Temporary Residence
53. Director, Regional Processing Center

Approved

Denied

Denied
54. ID Number

55. Date

Form I-687 (11/13/06)Y Page 7

OMB No. 1615-0090; Expires 03/31/07

Department of Homeland Security
U.S. Citizenship and Immigration Services

Form I-687 Supplement

CSS/Newman (LULAC) Class Membership Worksheet
LEGALIZATION APPLICANTS: You must complete this Class Membership Worksheet and file it with your Form I-687 if you are
applying for legalization under the Immigration Reform and Control Act of 1986 (IRCS), 8 U.S.C. 1255a, pursuant to the settlement
agreeents reached in Catholic Social Services v. Ridge et al. (CSS) or Newman v. USCIS. (Newman/LULAC). Your completed
Form I-687, with fee, together with this worksheet must be received by USCIS no later than December 31, 2005.
In order to apply, answer every question on this Class Membership Worksheet, which is a supplement to your application for temporary
resident status. Provide your complete name and Alien Registration Number (A#) and mark your responses in the boxes provided below.
Family Name (in capital letters)

Given Name

Middle Name

A Number

1. During the period between May 5, 1987 and May 4, 1988, did you (or a parent or spouse) visit an office of the
former Immigration and Naturalization Service (INS) to apply for legalization, but were turned away because the
INS or the Qualified Designated Entity (QDE) believed that (1) you had traveled outside the United States after
November 6, 1986, without advance parole, OR (2) you had traveled outside the United States and returned after
January 1, 1982, with a visitor's visa, student visa or any other type of visa or travel document?

Yes

No

2. Did you enter the United States before January 1, 1982, and then reside in a continuous unlawful status, except
for brief absences, from before 1982 until the date you (or your parent or spouse) were turned away by the INS
when you (or your parent or spouse) tried to apply for legalization during 1987 to 1988?

DRAFT

3. Were you continuously physically present in the United States, except for brief, casual and innocent departures
from November 6, 1986, until the date you (or your parent or spouse) were turned away by the INS when you (or
your parent or spouse) tried to apply for legalization?
4. Have you ever been convicted of a felony or three or more misdemeanors committed in the United States, or
have you ever been convicted of crimes, or committed acts which make you inadmissible pursuant to any provision
of the Immigration and Nationality Act including but not limited to: section 212(a)(2)(A)(i)(I) (crime involving
moral turpitude); section 212(a)(2)(B) (multiple criminal convictions); section 212(a)(2)(C) (controlled substance
traffickers); Section 212(a)(2)(A)(i)(II) (controlled substances ); section 212(a)(3) (security and related grounds)?
5. Did you (or your parent or spouse) apply for a work permit or otherwise register for class membership under CSS
or Newman/LULAC before October 1, 2000. If "Yes," attach copies of any available proof (for example, your CSS
or Newman work permit).
6. When you (or your parent or spouse) visited the INS or a QDE during the legalization application period, did you
(or your parent or spouse) bring with you a completed legalization application and fee?
NOTE: If you answered "Yes" to Questions 1, 2 and 3 and "No" to Question 4, and "Yes" to either Question 5 or 6, your answers indicate
that you may be eligible for legalization under the settlement agreements.
APPLICANT'S CERTIFICATION:
I certify, under the penalty of perjury under the laws of the United States of America, that this worksheet and the evidence submitted with
it are all true and correct. I authorize the release of any information from the records that the U.S. Department of Homeland Security needs
to determine eligibility for the benefit I am seeking.
I understand that information I provide in connection with this Class Membership Worksheet is confidential and may not be used to arrest,
remove or deport me or for any purpose unrelated to the adjudication of this Class Membership Worksheet, except as provided in 8 U.S.C.
1255a(c)(5).
Signature

Date

Form I-687 Supplement (11/13/06)Y Page 8


File Typeapplication/pdf
File Modified2006-11-24
File Created2006-11-24

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