Form I-687 Application for Status as a Temporary Resident Under Sec

OMB No.1615-0090; Expires 06/30/2010

Form 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)

Given Name

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

Middle Name

4. Other Names Used or Known by (Including maiden name, if married) 5. Telephone Numbers (Including Area Codes)
Home:
6. Home Address in the U.S.

Work:
U.S. Social Security #

In care of
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 (05/27/08)Y

11. Marital Status
Now Married

Never Married

13. Race

12. Gender
Male
Female

Separated

Divorced

Asian or Pacific Islander

Black, not of Hispanic origin

Hispanic

White, not of Hispanic origin

Widowed
Other (specify below)

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

16. When did you last come to the U.S.? 17. Manner of Entry
(mm/dd/yyyy)

Without a visa

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

18. Place of last entry into U.S.
Port of Entry (City and State)

Border - Not through a Port of Entry (State)

19. Mother's Name
(Give maiden name,
last name, first name)

Living
Deceased (year)

20. Father's Name
Living
(Give last name, first
Deceased (year)
name)
If you were admitted as a nonimmigrant prior to January 1, 1982, complete Numbers 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 (mm/ Present
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

Form I-687 (05/27/08)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)

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
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 (05/27/08)Y Page 3

31. AFFILIATIONS OR ASSOCIATIONS: 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. ABSENCES 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

Purpose of Trip

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

Form I-687 (05/27/08)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)
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 (05/27/08)Y Page 5

33. EMPLOYMENT IN THE UNITED STATES SINCE ENTRY, continued.
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)

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 (05/27/08)Y Page 6

33. EMPLOYMENT IN THE UNITED STATES SINCE ENTRY, continued.
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)

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 (05/27/08)Y Page 7

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?

Yes

No

Have you ever been arrested, cited or detained by any law enforcement officer
(including USCIS or former INS and military officers) for any reason?

Yes

No

Have you ever been charged with committing any crime or offense?

Yes

No

Have you ever been convicted of a crime or offense?

Yes

No

Have you ever been in jail or prison?

Yes

No

Have you ever been placed in an alternative sentencing or a rehabilitative program
(for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)?

Yes

No

Have you ever received a suspended sentence, been placed on probation, or been paroled?

Yes

No

Yes

No

Yes
Yes
Yes

No
No
No

38. Have you, or a dependent member of your immediate family, ever received public assistance from any
source, including, but not limited to, the U.S. Government, any state, county, city, or municipality?

39. Have you ever:
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?
c. Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally?

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

No

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 (05/27/08)Y Page 8

Have you ever left the United States to avoid being drafted into the U.S. 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 U.S. 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 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

Date

Print Name

Telephone number with area code

Address

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 (05/27/08)Y Page 9

OMB No. 1615-0090; Expires 06/30/2010

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?
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 (05/27/08)Y Page 10