Form I-817 Form I-817 Application for Benefits Under the Family Unity Program

OMB No. 1615-0005; Expires 11/30/09

I-817, Application for
DRAFT - Not For Production
Family Unity Benefits

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

START HERE - Type or print in black ink

Part 1. Information About You (Person requesting Family Unity Benefits)
Family Name (Last Name)

Full Middle Name

Given Name (First Name)

Date of Birth (mm/dd/yyyy)

A-Number (if any)

Country of Birth

Country of Citizenship

U.S. Social Security No. (if any)

Gender
Male

State

Date
Date
Resubmitted
Date

Female

Date
Reloc Sent

Home Address: Street Number and Name (include apartment number)
City

For USCIS Use Only
Returned
Receipt

Zip Code

Date

Mailing Address: (if different from home address)

Date
Reloc Rec'd

C/O: (In Care Of)

Date

City

State

Zip Code

Daytime Phone Number (include area code)

Date
Applicant
Interviewed
on
Remarks

Part 2. Basis for Application
1. I am applying for family unity benefits because: (Check one box)
A.
B.
C.

D.

E.

F.

G.

H.

I am the spouse of an alien who was legalized under section 245A of the INA, and we
have been married since at least May 5, 1988.
I am the spouse of an alien who was legalized as a Special Agricultural Worker under
section 210 of the INA, and we have been married since at least December 1, 1988.
As of May 5, 1988, I was the unmarried child under the age of 21 of an alien who was
legalized under section 245A of the INA. I am currently the child, son, or daughter of
the same parent. That parent is either a legalized alien or a naturalized U.S. citizen who
was a legalized alien on or before May 5, 1988, and maintained such status until his or
her naturalization.
As of December 1, 1988, I was the unmarried child under 21 years of age of an alien
who was legalized as a Special Agricultural Worker under section 210 of the INA. I am
currently the child, son, or daughter of the same parent. That parent is either a legalized
alien or a naturalized U.S. citizen who was a legalized alien on or before December 1,
1988, and maintained such status until his or her naturalization.
I am the spouse of a legalized alien who adjusted under section 202 of the Immigration
Reform and Control Act of 1986 (Cuban/Haitian Adjustment), and we have been married
since at least May 5, 1988.
As of May 5, 1988, I was the unmarried child under 21 years of age of an alien who
adjusted under section 202 of the Immigration Reform and Control Act of 1986
(Cuban/Haitian Adjustment). I am currently the child, son, or daughter of the same
parent. That parent is either a legalized alien or a naturalized U.S. citizen who was a
legalized alien on or before May 5, 1988, and maintained such status until his or her
naturalization.
I am the spouse of an alien who is eligible for and has filed for adjustment under section
1504 of P. L. 106-554, the LIFE Act Amendments. I entered the United States before
December 1, 1988, and was in the United States on that date.
I am the unmarried child of an alien who is eligible for and has filed for adjustment
pursuant to section 1504 of P. L. 106-554, the LIFE Act Amendments. I entered the
United States before December 1, 1988, and was in the United States on that date.

Action Block

Initial Application
Approved
Denied
Valid from:
to:
Request for Extension
Approved
Denied
Valid from:
to:
To Be Completed by
Attorney or Representative, if any
Fill in box if G-28 is attached to
represent the applicant.
ATTY State License #

Form I-817 (Rev. 08/20/10) Y

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Part 2. Basis for Application (Continued)
2. I am requesting: (Check one box)

Initial family unity benefits under section 301 of IMMACT 90.
An extension of family unity benefits under section 301 of IMMACT 90.
Initial family unity benefits under section 1504 of P. L. 106-554, the LIFE Act Amendments.

3. I am claiming relationship to: (Check one box)
A legalized alien under section 301 of IMMACT 90.
An alien who is eligible for and has filed for adjustment under section 1504 of P. L. 106-554, the LIFE Act Amendments.

Part 3. Additional Information
1. At the time of your last entry into the United States, you:
a.

were inspected and admitted

b. Date of last arrival
(mm/dd/yyyy)

were inspected and paroled

I-94, Arrival-Departure
Document No.

entered without inspection

Current or most recent
immigration status

Date status expires
(mm/dd/yyyy)

Date continuous U.S. residence
began (mm/dd/yyyy)

2. Give the U.S. address where you lived on May 5, 1988 (sec. 245A/Cuban Haitian Adjustment) or December 1, 1988 (sec. 210/LIFE Act)
Street number and name (Include apartment number)

City

State

3. Have you ever applied before for the Family Unity Program?
Name under which you applied:

City and state where application was filed

Zip Code

No

Yes (If "Yes," provide the following information)

USCIS action taken on case:

Date filed (mm/dd/yyyy)

Approved

Denied

4. If separate applications for family unity benefits are being submitted at this time for other relatives, give the following information:
Family Name (Last Name)

First Name

Middle Name

Relationship

A-Number

5. List all other names you have used including maiden name.

6. List all absences from the United States since May 5, 1988 or December 1, 1988, as appropriate, or since the approval of your last family unity
application (Form I-817), whichever date is later.
Date of Departure (mm/dd/yyyy)

Date of Return (mm/dd/yyyy)

Date of Departure (mm/dd/yyyy)

Date of Return (mm/dd/yyyy)

NOTE: If you need more space to complete an answer, use a separate sheet of paper. Write your name and A-Number, if you have
one, at the top of each sheet and indicate the number of the item that refers to your answer.
Form I-817 Form (Rev. 08/20/10) Y Page 2

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Part 3. Additional Information (Continued)

7. List all residences in the United States since May 5, 1988 or December 1, 1988, as appropriate, or since the approval of your last Family Unity
application (Form I-817), whichever date is later.
Street Number and Name (Include Apartment #)

City

State

Zip Code

Dates of Residence
From

To

From

To

From

To

From

To

From

To

From

To

8. Do you have or have you ever had:
a. A communicable disease of public health significance (including chancroid, gonorrhea, granuloma
inguinal, humanimmunodeficiency virus (HIV) infection, infectious leprosy, lymphogranuloma
venereum, infectious stage syphilis, or active tuberculosis)?

Present

Yes

No

Yes

No

a. Knowingly committed a crime for which you have not been arrested?

Yes

No

b. Been convicted of a felony or three or more misdemeanors in the United States?

Yes

No

c. Been convicted of two or more offenses for which the aggregate sentences were five or more years of
confinement?

Yes

No

d. Been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance?

Yes

No

e. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?

Yes

No

f.

Yes

No

Yes

No

b. A physical or mental disorder and behavior associated with the disorder which has posed or may pose a threat to
the property, safety, or welfare of yourself or others?
9. Have you ever:

Illicitly trafficked in any controlled substance or knowingly assisted, abetted, or colluded with others in the
illicit trafficking of any controlled substance?

g. Committed a criminal offense in the United States and asserted immunity from prosecution?

If you answered "Yes" to any of questions in Number 9, attach a copy of the arrest record and court disposition to this petition.
10. Have you, at any time within the past three years, engaged in the non-medical use of any drug listed in section
202 of the Controlled Substances Act (including, but not limited to, sedative, hypnotic, or anxiolytic substances
[tranquilizers], amphetamines, cannabinoids, cocaine, hallucinogens, opioids, phencyclidine [PCP], or related
substances)?
11. Have you, at any time within the past two years, engaged in the use of any psychoactive substance not listed in
section 202 of the Controlled Substance Act (including, but not limited to, alcohol and inhalants) which resulted in
behavior that has posed a threat to the property, safety, or welfare of yourself or others or which behavior is likely
to recur or to lead to other harmful behavior?

Yes

No

Yes

No

a. A felony crime of violence that has as an element the use or attempted use of physical force against another?

Yes

No

b. A felony offense that by its nature involves a substantial risk that physical force against another may be used in
the course of committing the offense?

Yes

No

13. Do you intend to engage solely, principally, or incidentally in prostitution in the United States, or are you now or
have you within the past 10 years, engaged in, procured, or received income from prostitution?

Yes

No

14. Have you been or do you intend to be involved in any commercial vice?

Yes

No

15. Have you ever practiced or do you intend to practice polygamy?

Yes

No

16. 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 other immigration benefit?

Yes

No

12. Have you ever committed an act of juvenile delinquency, which if committed by an adult would be classified as
follows: (If you are a LIFE ACT applicant skip this question.)

Form I-817 (Rev. 08/20/10) Y Page 3

DRAFT - Not For Production

Part 3. Additional Information (Continued)

17. Have you ever falsely represented yourself to be a citizen of the United States for any purpose or benefit under the
Immigration and Nationality Act or any Federal or State law?

Yes

No

18. Are you a former citizen of the United States who renounced your U.S. citizenship for the purpose of avoiding
taxation by the United States?

Yes

No

19. Have you ever been an F-1 nonimmigrant student who violated status by attending a public elementary or secondary
school in violation of immigration law?

Yes

No

20. Have you ever failed or refused to attend or remain in attendance at a hearing to determine your admissibility to or
deportability from the United States?

Yes

No

21. Have you ever been identified by USCIS as having obtained transportation to the United States
without the consent of the owner, charterer, master, or person in charge of the vessel or aircraft through
concealment onboard such vessel or aircraft on which you arrived?

Yes

No

22. Have you been ordered deported, excluded, or removed from the United States?

Yes

No

23. Have you ever departed the United States after having been unlawfully present for 180 days but less than 365 days?

Yes

No

24. Have you ever departed the United States after having been unlawfully present for 365 days or longer?

Yes

No

25. Have you ever knowingly encouraged, induced, assisted, abetted, or aided anyone to enter the United States in
violation of the law?

Yes

No

26. Were you a guardian required to accompany an individual certified as helpless who was found to be inadmissible to
the United States?

Yes

No

27. Have you detained, retained, or withheld the custody of a U.S. citizen child outside the United States from a person
granted custody of such child by a U.S. court order?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

a. Ever engaged in, conspired to engage in, or intended to engage in a terrorist activity?

Yes

No

b. Ever incited terrorist activity with intent to cause death or serious bodily harm?

Yes

No

c. Ever been a representative of a terrorist organization or a member of an organization which you knew or should
have known is a terrorist organization?

Yes

No

Yes

No

a. Ever been, or are you now, a member of the Communist or other totalitarian party?

Yes

No

b. Ever engaged in genocide, or ordered, incited, assisted or otherwise participated in the persecution of any
person because of race, religion, national origin, membership in a particular social group, or political opinion?

Yes

No

32. During the periods of 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,
did you ever order, incite, assist, or otherwise participate in the persecution of any person because of race,
religion, national origin, or political opinion?

Yes

No

33. Have you ever left the United States to avoid being drafted into the U.S. Armed Forces?

Yes

No

34. Have you received public assistance from any source, including the U.S. Government or any State, county, city, or
other municipality, or are you likely to request public assistance in the future?

Yes

No

35. Have you ever been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence
requirement and not yet complied with the requirement?

Yes

No

36. Have you ever voted in violation of any Federal, State, or local constitutional provision, statute, ordinance,
or regulation?

Yes

No

28. Have you ever engaged in, conspired to engage in, or intended to engage solely, principally, or incidentally in:
a. Any activity to violate any U.S. law relating to espionage or sabotage?
b. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or
sensitive information?
c. Any other activity the purpose of which is in opposition to, or the control of, or overthrow of the Government of
the United States, by force, violence, or other unlawful means?
d. Any other unlawful activity?
29. Have you:

30. Have you ever engaged in or do you intend to engage in any activity in the United States that would have
potentialy serious adverse foreign policy consequences for the United States?
31. Have you:

NOTE: If you answered "Yes" to any of the above questions, provide a full explanation on a separate sheet of paper.
Form I-817 (Rev. 08/20/10) Y Page 4

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Part 4. Information About Your Spouse or Parent (Your spouse or parent must be either a legalized
alien or an alien eligible for adjustment pursuant to the LIFE Act)
1. Provide the following information about the alien through whom you are claiming your eligibility.
Full Middle Name
Family Name (Last Name)
Given Name (First Name)

Date of Birth (mm/dd/yyyy)

A-Number (if any)

U.S. Social Security No. (if any) Class of Admission

Gender
Male

Female

Home Address: Street Number and Name (include apartment number)

City

State

Zip Code

Daytime Phone No. (Area Code)

2. List all other names used, including maiden name.

Part 5. Complete Only If You Are Applying Based on a Marital Relationship
1. Provide the following information about you and your spouse.
Number of times you have been married

Number of times your spouse has been married

2. Provide the following information about your current marriage.
Date of marriage (mm/dd/yyyy)

Place of marriage (City, State or province, and country)

3. Type of ceremony.
Religious

4. We are:
Civil

None

Living together

Not living together

Part 6. Complete Only If You Are Applying Based on a Child/Parent Relationship
1. Indicate how your parent is related to you.
Biological mother
Biological father who was married to my mother when I was born
Biological father who was not married to my mother when I was born.
Stepparent - based on marriage to my parent which occurred before my 18th birthday
Adoptive parent and:
a. The adoption occurred before my 16th birthday

Yes

No

b. My adoptive parent had legal custody of me for at least two years prior to May 5,
1988 or December 1, 1988, as appropriate

Yes

No

c. I lived with my adoptive parent for at least two years prior to May 5, 1988 or
December 1, 1988, as appropriate

Yes

No

Parent based on circumstances not described above (Explain in detail on a seperate sheet of paper.)
2. Give the following information about your marital status.
Single

Married

Divorced

Widowed

3. Provide the following information if you are married, divorced, or widowed.
Date of marriage (mm/dd/yyyy)

Place of marriage (City, State or province, and country)

4. Type of ceremony.
Religious

5. We are:
Civil

6. If divorced or widowed:
Date marriage ended (mm/dd/yyyy)

None

Living together

Not living together

Place marriage ended (City, State or province, and country)

Form I-817 (Rev. 08/20/10) Y Page 5

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Part 7. Signature (Read the information on penalties in the instructions before completing this section.)
I certify, under penalty of perjury under the laws of the United States of America, that the information provided with this application
is all true and correct. I certify also that I have not withheld any information that would affect the outcome of this application. I
authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to determine
eligibility for the benefit being sought.
Signature

Date (mm/dd/yyyy)

Part 8. Signature of Person Preparing Form, If Other Than Above (Sign below)
I declare that I prepared this application at the request of the above person and it is based on all information of which I have
knowledge. I have not knowingly withheld any material information that would affect the outcome of this application.
Attorney or Representative: In the event of a Request for Evidence (RFE), may USCIS contact you by Fax or E-Mail?
Yes

No

Preparer's Signature

Preparer's Printed Name

Date (mm/dd/yyyy)

Preparer's Firm Name (if applicable)

Preparer's Address

Daytime Phone Number (with area code)

Fax Number (if any)

E-Mail Address (if any)

Signature for Placement On Employment Authorization Document
Provide your signature below. This signature will be scanned and duplicated for placement on your Employment Authorization
Document. When signing, make sure that no part of your signature goes outside the lines of the box.

Signature

Form I-817 (Rev. 08/20/10) Y Page 6