Form I-360 Form I-360 Petition for Amerasian, Widow or Special Immigrant

OMB No. 1615-0020; Expires 12/31/2010

I-360, Petition for Amerasian,
Widow(er), or Special Immigrant

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

START HERE - Type or print in black ink

For USCIS Use Only

Part 1. Information About Person or Organization Filing This
Petition (Individuals use the top name line; organizations use the second
line.) If you are a self-petitioning spouse or child and do not want USCIS to
send notices about this petition to your home, you may show an alternate
mailing address here. If you are filing for yourself and do not want to use an
alternate mailing address, skip to Part 2.
1b. Given Name
1a. Family Name
1c. Middle Name

Receipt

Resubmitted

Reloc Sent

2. Company or Organization Name

3. Address - C/O

Reloc Rec'd

4. Street Number and Name

6. City

Returned

5. Apt. #

7. State or Province

8. Country

9. Zip/Postal Code

Petitioner/
Applicant
Interviewed
Beneficiary
Interviewed
I-485 Filed Concurrently
Bene "A" File Reviewed

12. IRS Tax # (if any)

10. U.S. Social Security Number 11. A-Number

Classification
Consulate

Part 2. Classification Requested (Check one):
Priority Date

a. Amerasian
b. Widow(er) of a U.S. citizen

Remarks:

c. Special Immigrant Juvenile
d. Special Immigrant Religious Worker
Will the alien be working as a minister?

Yes

No

Action Block

e. Special Immigrant based on employment with the Panama Canal Company,
Canal Zone Government, or U.S. Government in the Canal Zone
f.

Special Immigrant Physician

g. Special Immigrant International Organization Employee or family member
h. Special Immigrant Armed Forces Member
i.

Self-Petitioning Spouse of Abusive U.S. Citizen or Lawful Permanent Resident

j. Self-Petitioning Child of Abusive U.S. Citizen or Lawful Permanent Resident
k. Special Immigrant Afghanistan or Iraq National who worked with the U.S.
Armed Forces as a translator
l. Special Immigrant Iraq National who was employed by or on behalf of the
U.S. Government

To Be Completed By
Attorney or Representative, if any
Fill in box if Form G-28 is attached to
represent the applicant
VOLAG#
ATTY State License #

m. Other, explain:
Form I-360 (Rev. 11/23/10)Y

Part 3. Information About the Person for Whom This Petition Is Being Filed
1a. Family Name (Last Name)

2.

1c. Middle Name

1b. Given Name (First Name)

Address - C/O
3b. Apt. Number

3a. Street Number and Name

4.

City

5. State or Province

6.

Country

7. Zip/Postal Code

8.

Date of Birth
(mm/dd/yyyy)

12. Marital Status:

10. U.S. Social Security # 11. A-Number (if any)

9. Country of Birth

Single

Divorced

Married

Widowed

13. Complete the items below if this person is in the United States:
a.

Date of Arrival (mm/dd/yyyy)

c. I-94 Number

b.

Current Nonimmigrant Status

d. Expires on (mm/dd/yyyy)

Part 4. Processing Information
1.

Provide information on which U.S. consulate you want notified if this petition is approved, and if any requested adjustment of
status cannot be granted.
a.

2.

U.S. Consulate: City

b. Country

If you gave a U.S. address in Part 3, print the person's foreign address below. If his or her native alphabet does not use Roman
letters, print his or her name and foreign address in the native alphabet.
a.

Name

c.

Gender of the person for whom this petition is being filed:

Male

Female

d.

Are you filing any other petitions or applications with this
one?

No

Yes

e.

Is the person this petition is for in deportation or removal
proceedings?

No

Yes (Explain on a separate sheet of paper)

f.

Has the person for whom this petition is being filed ever
worked in the U.S. without permission?

No

Yes (Explain on a separate sheet of paper)

g.

Is an application for adjustment of status attached to this
petition?

No

Yes (Attach a full explanation)

b. Address

(How many?

)

Form I-360 (Rev. 11/23/10)Y Page 2

Part 5. Complete Only If Filing for an Amerasian
Section A. Information about the mother of the Amerasian
1a. Family Name

2. Living?

1c. Middle Name

1b. Given Name

No (Give date of death

)

Unknown

Yes (Complete address line below)

3. Address

Section B. Information about the father of the Amerasian:
If possible, attach a notarized statement from the father regarding parentage. Explain on a separate paper any question you cannot fully
answer in the space provided on this form. (Attach a full explanation.)
1a. Family Name

1b. Given Name

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

3. Country of Birth

4. Living?

)

No (Give date of death

1c. Middle Name

Unknown

Yes (Complete address line below)

5. Home Address
7. Work Phone Number

6. Home Phone Number

8. At the time the Amerasian was conceived:
a. The father was in the military (indicate branch of service below and give service number here):
Army

Air Force

Navy

Marine Corps

Coast Guard

b.

The father was a civilian employed abroad. Attach a list of names and addresses of organizations which employed him at that
time.

c.

The father was not in the military and was not a civilian employed abroad. (Attach a full explanation of the circumstances.)

Part 6. Complete Only If Filing for a Special Immigrant Juvenile Court Dependent
Section A. Information about the juvenile
List any other names used

Answer the following questions regarding the person for whom the petition is being filed. If you answer "No," explain on a separate
sheet of paper.
a. Have you been declared dependent upon a juvenile court in the United States, or have you been
legally committed to, or placed under the custody of, an agency or department of a State, or an
individual or entity appointed by a State or juvenile court?

No

Yes

b. Has a juvenile court declared that reunification with one or both of your parents is not viable due to
abuse, neglect, abandonment, or a similar basis under State law?

No

Yes

c. Have you been the subject of proceedings in which it was determined that it would not be in your best
interest to be returned to your or your parent's country of nationality or last habitual residence?

No

Yes

Form I-360 (Rev. 11/23/10)Y Page 3

Part 7. Complete Only if Filing as a Widow/Widower, a Self-petitioning Spouse of an Abuser,
or as a Self-petitioning Child of an Abuser
Section A. Information about the U.S. citizen husband or wife who died or about the U.S. citizen or lawful
permanent resident abuser
1c. Middle Name

1b. Given Name

1a. Family Name

4. Date of Death (mm/dd/yyyy)

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

5. He or she is now, or was, at time of death a (check one):
a. U.S. citizen born in the United States
b. U.S. citizen born abroad to U.S. citizen parents
c. U.S. lawful permanent resident (Provide A#)
d. U.S. citizen through naturalization (provide A#)
e. Other, explain

Section B. Additional information about you
1. How many times have you
been married?

2. How many times was the
person in Section A married?

4. When did you live with the person named in Section A?

3. Give the date and place where you and the person in Section A
were married. (If you are a self-petitioning child, write "N/A")

From (Month/Year)

5. If you are filing as a widow/widower, were you legally separated at the
time of the U.S citizen's death?

until (Month/Year)
No

Yes (Attach explanation)

6. Give the last address at which you lived together with the person named in Section A, and show the last date that you lived
together with that person at that address:

7. If you are filing as a self-petitioning spouse, have any of your children
filed separate self-petitions?

No

Yes (Show child(ren)'s full names):

Form I-360 (Rev. 11/23/10)Y Page 4

Part 8.

Complete Only If Filing a Special Immigrant Religious Worker Petition

Employer Attestation

1. Provide the following information about the prospective employer:
a. Number of members of the prospective employer's organization:
b. Number of employees working at the same location where the beneficiary will be
employed:
c. Number of aliens holding special immigrant or nonimmigrant religious worker status
currently employed or employed within the past 5 years:
d. Number of Special Immigrant Religious Worker I-360 and Nonimmigrant Religious
Worker I-129 Petitions submitted by the prospective employer within the past 5 years:
2. Has the alien or any of the alien's dependent family members previously been admitted to the
United States for a period of stay in the R classification for the last 5 years?

No

Yes

If "Yes," complete the table below. List the alien and any dependent family member's prior periods of stay in the R classification in
the United States for the last 5 years. Be sure to list only those periods in which the alien and/or family members were actually in
the United States in the R classification.
NOTE: Submit photocopies of Form I-94 (Arrival-Departure Record), Form I-797 (Notice of Action), and/or other USCIS
documents identifying these periods of stay in the R classification. If more space is needed, provide the information on additional
sheets of paper.
Alien or Dependent Family Member's Name

Period of Stay (mm/dd/yyyy)
From:
To:

Form I-360 (Rev. 11/23/10)Y Page 5

3. Provide a summary of the type of responsibilities of those employees who work at the same location where the beneficiary will be
employed. If additional space is needed, provide the information on additional sheets of paper.
Position

Summary of the Type of Responsibilities for That Position

4. Describe the relationship, if any, between the religious organization in the United States and the organization abroad of which the
alien is a member.

5

Provide the following information about the prospective employment:
a. Title of position offered.

b. Detailed description of the alien's proposed daily duties.

Form I-360 (Rev. 11/23/10)Y Page 6

c. Description of the alien's qualifications for the position offered.

d. Description of the proposed salaried and/or non-salaried compensation.

e. List of the specific address(es) or location(s) where the alien will be working.

Does the prospective employer attest to all of the requirements described in statements 6 through 12 below?
6. The prospective employer is a bona fide non-profit religious organization or a bona fide organization that is affiliated with the
religious denomination and is tax exempt as described in section 501(c)(3) of the Internal Revenue Code of 1986, subsequent
amendment, or equivalent sections of prior enactments of the Internal Revenue Code. If the prospective employer is affiliated with
the religious denomination, complete the Religious Denomination Certification included in this form.
Yes

No (If "No," attach explanation(s))

7. The prospective employer is willing and able to provide salaried and/or non-salaried compensation at a level that the alien and any
dependents will not become a public charge.
Yes

No (If "No," attach explanation(s))

8. The funds to pay the prospective employee’s compensation do not include any monies obtained from the alien, excluding
reasonable donations or tithing to the religious organization.
Yes

No (If "No," attach explanation(s))

9. If the position is not a religious vocation, the prospective employee will not engage in secular employment, and the prospective
employer will provide salaried and/or non-salaried compensation.
Yes

No (If "No," attach explanation(s))

Form I-360 (Rev. 11/23/10)Y Page 7

10. The offered position is full time, requiring at least an average of 35 hours of work per week.
Yes

No

(If "No," attach explanation(s))

11. The alien has been a religious worker for at least 2 years immediately before Form I-360 was filed and is otherwise qualified for
the position offered.
Yes

No

(If "No," attach explanation(s))

12. The alien has been a member of the prospective employer’s denomination for at least 2 years immediately before Form I-360 was
filed.
Yes

No

(If "No," attach explanation(s))

I certify or attest under penalty of perjury under the laws of the United States of America that the contents of this
attestation, and the evidence submitted, are true and correct.
Signature

Date (mm/dd/yyyy)

Printed Name

Title

Employer/Organization Name

Employer/Organization Street Address (Do not use a post office or private mail box)

City

Daytime Phone Number
(with area code)

Suite Number

State

Fax Number (if any)

Zip Code

E-Mail Address (if any)

Form I-360 (Rev. 11/23/10)Y Page 8

Religious Denomination Certification
I certify under penalty of perjury under the laws of the United States of America that:

Name of Employing Organization

is affiliated with:
Name of Religious Denomination

and that the attesting organization within the religious denomination is tax exempt as described in section under 501(c)(3) of the
Internal Revenue Code of 1986, subsequent amendment, or equivalent sections of prior enactments of the Internal Revenue Code. The
contents of this certification are true and correct to the best of my knowledge.
Signature
Printed Name
Title
Date (mm/dd/yyyy)
Attesting Organization Name
Attesting Organization Street Address
(Do not use a post office or private mail box)
Suite Number
City
State
Zip Code
Daytime Phone Number (with area code)
Fax Number (if any)
E-Mail Address (if any)

Form I-360 (Rev. 11/23/10)Y Page 9

Part 9. Information About the Spouse and Children of the Person for Whom This Petition Is Being Filed
A widow/widower or a self-petitioning spouse of an abusive citizen or lawful permanent resident should also list the
children of the deceased spouse or of the abuser.

1a. Family Name

1d. Date of Birth
(mm/dd/yyyy)

1b. Given Name

1e. Country of Birth

1c. Middle Name

1f. Relationship

1g. A-Number

Spouse
Child

2a. Family Name

2d. Date of Birth
(mm/dd/yyyy)

2b. Given Name

2e. Country of Birth

3b. Given Name

3e. Country of Birth

3f. Relationship

4e. Country of Birth

3g. A-Number

4c. Middle Name

4f. Relationship

4g. A-Number

Child

5b. Given Name

5e. Country of Birth

5c. Middle Name

5f. Relationship

5g. A-Number

Child

6a. Family Name

6d. Date of Birth
(mm/dd/yyyy)

3c. Middle Name

4b. Given Name

5a. Family Name

5d. Date of Birth
(mm/dd/yyyy)

2g. A-Number

Child

4a. Family Name

4d. Date of Birth
(mm/dd/yyyy)

2f. Relationship
Child

3a. Family Name

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

2c. Middle Name

6b. Given Name

6e. Country of Birth

6c. Middle Name

6f. Relationship

6g. A-Number

Child

Form I-360 (Rev. 11/23/10)Y Page 10

Part 9. Information About the Spouse and Children of the Person for Whom This Petition Is Being Filed
A widow/widower or a self-petitioning spouse of an abusive citizen or lawful permanent resident should also list the
children of the deceased spouse or of the abuser. (Continued)
7a. Family Name

7d. Date of Birth
(mm/dd/yyyy)

7b. Given Name

7e. Country of Birth

8b. Given Name

8e. Country of Birth

7g. A-Number

8c. Middle Name

8f. Relationship

8g. A-Number

Child

9a. Family Name

9d. Date of Birth
(mm/dd/yyyy)

7f. Relationship
Child

8a. Family Name

8d. Date of Birth
(mm/dd/yyyy)

7c. Middle Name

9b. Given Name

9e. Country of Birth

9c. Middle Name

9f. Relationship

9g. A-Number

Child

Part 10. Signature
Read the information on penalties in the instructions before completing this part. If you will be filing this petition at a
USCIS office in the United States, sign below. If you will be filing it at a U.S. consulate or USCIS office overseas, sign in
front of a USCIS or consular official.
I certify, or, if outside the United States, I swear or affirm, under penalty of perjury under the laws of the United States of America,
that this petition and the evidence submitted with it is all true and correct. If filing this on behalf at an organization, I certify that I am
empowered to do so by that organization. I authorize the release of any information from my records, or from the petitioning
organization's records, that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit being sought.
Signature

Signature of USCIS
or Consular Official

Date

Print Name

E-Mail Address

Date

NOTE: If you do not completely fill out this petition or fail to submit required documents listed in the instructions, the person(s) filed
for may not be found eligible for a requested benefit, and the petition may be denied.

Form I-360 (Rev. 11/23/10)Y Page 11

Part 11. 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.
Signature

Date

E-Mail Address

Print Your Name

Firm Name and Address

Form I-360 (Rev. 11/23/10)Y Page 12