I-817 Application for Family Unity Benefits

Application for Family Unity Benefits

USCIS
Form I-817

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

OMB No. 1615-0005
Expires 02/28/2013

Action Block

Fee Stamp

For USCIS Use Only
Returned

DRAFT Not
For Production

Resubmitted

Received
Sent

Initial Application

Remarks:

Valid

Approved

From
To

Denied

/

/

Request for Extension

/

/

To Be Completed by an Attorney or a BIAAccredited Representative, if any.

/

/

Approved

Valid

Relocated

From
To

Denied

/

/

/

/

/

/

Fill in box if G-28 is attached to represent the applicant.
Attorney State License Number:

►START HERE - Type or print in black ink.

Part 1. Information About You (Person Requesting
Family Unity Benefits)

1.

7.

Gender (Check the appropriate box)

8.

Country of Birth

9.

Country of Citizenship

Male

Female

Alien Registration Number (A-Number)
► A-

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Full Middle
Name

Physical Address
10.a. Street Number
and Name
10.b. Apt.

Ste.

Flr.

Other Names Used (Including maiden name)
10.c. City or Town

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Full Middle
Name

10.e. Zip Code

10.d. State

Mailing Address
11.a. In Care of Name

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Full Middle
Name

11.b. Street Number
and Name
11.c. Apt.

Ste.

Flr.

11.d City or Town

Other Information
11.e. State

11.f. Zip Code

(mm/dd/yyyy) ►

5.

Date of Birth

6.

U.S. Social Security Number (if any)
►

Form I-817 Instructions 09/18/12 N

Page 1 of 10

Part 1. Information About You (Person Requesting
Family Unity Benefits)(continued)
Contact Information
12.

Daytime Phone Number (if any)

(
13.

Extension

NOTE: To be eligible for IMMACT 90 Family Unity Program
benefits, your qualifying spouse or parent must have maintained
his or her status as a legalized alien or as a U.S. citizen, if he or
she naturalized. If deceased, status must have been maintained
until his or her death. For LIFE Act Family Unity, your spouse
or parent must be eligible for adjustment or adjusted status
under section 1504 of the LIFE Act Amendments. If you
previously qualified for LIFE Act Family Unity, you may be
eligible to apply for IMMACT 90 Family Unity Program
Benefits.

DRAFT Not
For Production
)

-

E-Mail Address (If any)

2. I am requesting: (Select only one box)

Part 2. Basis For Application

a.

Initial Family Unity benefits under section 301 of
IMMACT 90.

1. I am applying for Family Unity benefits because:
(Select only one box)

b.

An extension of Family Unity benefits under section 301
of IMMACT 90.

a.

On May 5, 1988, I was the spouse of an alien who was
legalized under section 245A of the INA;

c.

Initial Family Unity benefits under section 1504 of P.L.
106-554, the LIFE Act Amendments.

b.

On December 1, 1988, I was the spouse of an alien who
was legalized as a Special Agricultural Worker under
section 210 of the INA;

d.

An extension of Family Unity benefits under section
1504 of P.L. 106-554, the LIFE Act Amendments.

c.

On May 5, 1988, I was the unmarried child under age
21 of an alien who was legalized under section 245A of
the INA;

3. I am claiming relationship to: (Select only one box)
a.

A legalized alien under section 301 of IMMACT 90.

b.

An alien who is eligible for and has filed for adjustment,
or adjusted status under section 1504 of P.L. 106-554,
the LIFE Act Amendments.

d.

On December 1, 1988, I was the unmarried child under
age 21 of an alien who was legalized as a Special
Agricultural Worker under section 210 of the INA;

e.

On May 5, 1988, I was the spouse of a legalized alien
who adjusted status under section 202 of the
Immigration Reform and Control Act of 1986 (Cuban/
Haitian Adjustment);

A. Information About Your Spouse or Parent

On May 5, 1988, I was the unmarried child under age
21 and the following apply:

Provide the following information about the alien through
whom you are claiming your eligibility.

(1) On May 5, 1988, I was the child of an alien who
adjusted status under section 202 of the Immigration
Reform and Control Act of 1986 (Cuban/Haitian
Adjustment);

Spouse or Parent Information

f.

(2) That parent is either a legalized alien or a
naturalized U.S. citizen who was legalized on or
before May 5, 1988 and he or she maintained that
status until his or her naturalization; OR

Part 3. Information About Relationship

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Full Middle
Name
1.d. Date of Birth

(3) That parent has died, but he or she was either a
legalized alien or a naturalized citizen who was
legalized on or before May 5, 1988 and he or she
maintained that status until his or her death.
g.

I am the spouse of an alien who is eligible for and has
filed or adjusted status under section 1504 of P. L.
106-554, the LIFE Act Amendments. I entered the
United States on or before December 1, 1988, and
resided in the United States on that date;

(mm/dd/yyyy) ►

1.e. A-Number (if any)
► A1.f.

U.S. Social Security Number (if any)
►

1.g. Gender

Male

Female

1.h. Class of Admission (visitor, student, EWI, etc.)

Form I-817 Instructions 09/18/12 N

Page 2 of 10

Part 3. Information About Relationship (continued)

Provide the following information about your current marriage
(if married).

Spouse or Parent Information continued)

3.a. Date of
(mm/dd/yyyy) ►
Marriage
3.b. Place of Marriage (City or Town)

Physical Address in U.S.
2.a. Street Number
and Name

DRAFT Not
For Production

2.b. Apt.

Ste.

3.c. State

Flr.

3.d. Province

2.c. City or Town

3.e. Country

2.e. Zip Code

2.d. State

Contact Information
3.

(
4.

3.f.

Daytime Phone Number (if any)

)

Type of ceremony:

Religious

Civil

None

Extension

3.g. We are:

-

Living together

Not living together

3.h. If you checked "Not living together," (select one):

E-Mail Address (If any)

My spouse has died

We are divorced

We are separated

Other Names Used (Including maiden name)

Provide the following information about your prior marriages
(if any).

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Full Middle
Name

Prior Marriage Information
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Full Middle
Name

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Full Middle
Name

5.a. Date of Marriage (mm/dd/yyyy) ►
(if married)
5.b. Place of Prior Marriage (City or Town)

B. Complete If You Are Applying Based on a Marital
Relationship or You Were Previously Married

5.c. State

Provide the following information about your marital status.

5.d. Province

1.

5.e. Country

Marital Status
Single (never married)

Married

Widowed

Separated

Divorced
Date of
(mm/dd/yyyy) ►
Termination
5.g. Place of Termination (City or Town)
5.f.

Provide the following information about you and your spouse.
2.a. Number of times you have been married
(including current marriage) ►
2.b. Number of times your spouse has been married

5.h. State

(including spouse current marriage) ►

Form I-817 Instructions 09/18/12 N

Page 3 of 10

Part 3. Information About Relationship (continued)

7.k. Reason for Termination
Divorce

Prior Marriage Information (continued)
5.i.

Province

5.j.

Country

Death

Annulment

Other (Provide an explanation if there are any other
reasons for termination):

DRAFT Not
For Production

5.k. Reason for Termination
Divorce

Death

Annulment

Other (Provide an explanation if there are any other
reasons for termination):

C. 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

Provide the following information about YOUR SPOUSE'S
prior marriages (if any).

Stepparent - based on marriage to my parent which
occurred before my 18th birthday

Your Spouse's Prior Spouse's Information
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Full Middle
Name

Adoptive parent (select one):

a. The adoption occurred before my 16th birthday;
Yes

b. My adoptive parent had legal custody of me on
May 5, 1988, or December 1, 1988, (as
appropriate), and I resided with him or her for
2 years prior to that date.
Yes
No

7.a. Date of Marriage (mm/dd/yyyy) ►
(if any)
7.b. Place of Marriage (City or Town)

7.c. State

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

7.d. Province
7.e. Country

7.f.

No

Date of Termination
(mm/dd/yyyy) ►

Marital Status
Single (never married)

Married

Widowed

Separated

Provide the following information.
3.a. Date of Marriage (mm/dd/yyyy) ►

7.g. Place of Termination (City or Town)

3.b. Place of Marriage (City or Town)

7.h. State

3.c. State

7.i.

Province

3.d. Province

7.j.

Country

3.e. Country

3.f.

Type of ceremony:

3.g. We are:

Form I-817 Instructions 09/18/12 N

Divorced

Religious

Living together

Civil

None

Not living together

Page 4 of 10

Part 3. Information About Relationship (continued)

3.a. At the time of your last entry into the United States, you:
Were inspected and admitted

C. Complete Only If You Are Applying Based on a
Child/Parent Relationship (continued)

Were inspected and paroled
Entered without inspection

3.h. If you checked "Not living together," (select one):
My spouse has died

We are divorced

3.b. Date of Last Arrival

DRAFT Not
For Production
(mm/dd/yyyy) ►

We are separated

Provide the following information if divorced or widowed:
3.i.

Date Marriage Ended (mm/dd/yyyy) ►

3.j.

Place Marriage Ended (City or Town)

3.c. Form I-94, Arrival-Departure Record Number
►

3.d. Passport Number

3.e. Travel Document Number

3.k. State
3.l.

3.f.

Country of Issuance for Passport or Travel Document

Province

3.g. Expiration Date for Passport or Travel Document

3.m. Country

(mm/dd/yyyy) ►

3.h. Current or Most Recent Immigration Status

NOTE: If you were previously married, you must complete
Part 3 section B., entitled "Complete If You Are Applying
Based on a Marital Relationship or You Were Previously
Married", Item Numbers 1. - 7.k. of this form and complete
all requested information about your prior marriage(s) and
check the box it has been completed.
4.
I have completed Part 3, section B, item numbers
1. - 7.k., information about my prior marriage(s) (if any).

Part 4. Additional Information
1.

Have you ever applied before for the Family Unity
Program? (If "Yes," provide the following information)
Yes
No

Name Under Which You Applied
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Full Middle
Name
2.d. City or Town Where Application Was Filed

2.e. State
2.f.

Date Filed

(mm/dd/yyyy) ►

2.g. USCIS (or former INS) action taken on case
Approved

Denied

3.i.

3.j.

Date Status
(mm/dd/yyyy) ►
Expires
Date Continuous U.S. Residence Began
(mm/dd/yyyy) ►

Provide the U.S. address where you lived on May 5, 1988
(245A or Cuban Haitian Adjustment) or December 1, 1988
(section 210 or LIFE Act).
4.a. Street Number
and Name
4.b. Apt.

Ste.

Flr.

4.c. City or Town
4.d. State

4.e. Zip Code

If separate applications for Family Unity benefits are being
submitted at this time for other relatives, provide the following
information:
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Full Middle
Name
5.d. A-Number (if any)
► A5.e. Relationship to Applicant

Form I-817 Instructions 09/18/12 N

Page 5 of 10

Part 4. Additional Information (continued)
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Full Middle
Name
6.d. A-Number (if any)

10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)
10.c. Full Middle
Name
10.d. A-Number (if any)

DRAFT Not
For Production
► A-

► A-

10.e. Relationship to Applicant

6.e. Relationship to Applicant

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.

7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)
7.c. Full Middle
Name
7.d. A-Number (if any)

11.a. Departure Date (mm/dd/yyyy) ►
11.b. Return Date

► A-

7.e. Relationship to Applicant

(mm/dd/yyyy) ►

12.a. Departure Date (mm/dd/yyyy) ►
12.b. Return Date

(mm/dd/yyyy) ►

13.a. Departure Date (mm/dd/yyyy) ►
8.a. Family Name
(Last Name)
8.b. Given Name
(First Name)
8.c. Full Middle
Name
8.d. A-Number (if any)

13.b. Return Date

(mm/dd/yyyy) ►

14.a. Departure Date (mm/dd/yyyy) ►
14.b. Return Date

(mm/dd/yyyy) ►

► A8.e. Relationship to Applicant

15.a. Departure Date (mm/dd/yyyy) ►
15.b. Return Date

9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c. Full Middle
Name
9.d. A-Number (if any)

(mm/dd/yyyy) ►

16.a. Departure Date (mm/dd/yyyy) ►
16.b. Return Date

► A-

17.a. Departure Date (mm/dd/yyyy) ►
17.b. Return Date

9.e. Relationship to Applicant

Form I-817 Instructions 09/18/12 N

(mm/dd/yyyy) ►

(mm/dd/yyyy) ►

Page 6 of 10

Part 4. Additional Information (continued)

21.d. State

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.

21.f. Dates of Residence (mm/dd/yyyy)

21.e. Zip Code

From ►

To ►

DRAFT Not
For Production
Previous Residence 4

Current Residence

22.a. Street Number
and Name

18.a. Street Number
and Name
18.b. Apt.

Ste.

22.b. Apt.

Flr.

22.d. State

18.e. Zip Code

18.f. Dates of Residence (mm/dd/yyyy)
From ►

To ► PRESENT

Ste.

From ►

To ►

Flr.

23.e. Zip Code

23.f. Dates of Residence (mm/dd/yyyy)
From ►

To ►

Previous Residence 6

Previous Residence 2

24.a. Street Number
and Name

20.a. Street Number
and Name
Ste.

24.b. Apt.

Flr.

Ste.

Flr.

24.c. City or Town

20.c. City or Town

24.d. State

20.e. Zip Code

20.f. Dates of Residence (mm/dd/yyyy)
From ►

To ►

24.e. Zip Code

24.f. Dates of Residence (mm/dd/yyyy)
From ►

To ►

NOTE: If you need more space to complete an answer in Item
Numbers 5.a. - 24.f., 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 Part Number and Item Number of the item to
which your answer refers, and sign and date each sheet.

Previous Residence 3
21.a. Street Number
and Name
Ste.

Ste.

23.d. State

19.f. Dates of Residence (mm/dd/yyyy)

21.b. Apt.

To ►

23.c. City or Town
19.e. Zip Code

20.d. State

From ►

23.b. Apt.

Flr.

19.c. City or Town

20.b. Apt.

22.f. Dates of Residence (mm/dd/yyyy)

23.a. Street Number
and Name

19.a. Street Number
and Name

19.d. State

22.e. Zip Code

Previous Residence 5

Previous Residence 1

19.b. Apt.

Flr.

22.c. City or Town

18.c. City or Town
18.d. State

Ste.

Flr.

21.c. City or Town

Form I-817 Instructions 09/18/12 N

Page 7 of 10

Have you ever:

Part 4. Additional Information (continued)

31.

Answer the following questions:
Have you ever ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:

Been engaged any activity to violate any law of the
United States related to espionage or sabotage or to
violate or evade any law prohibiting the export from the
United States of goods, technology, or sensitive
information?
Yes
No

DRAFT Not
For Production

25.a. Acts involving torture or genocide?

Yes

No

25.b. Killing any person?

Yes

No

32.

Been convicted by a final judgment of a particularly
serious crime or participated in any other criminal activity
which endangers public safety or national security of the
United States?
Yes
No

33.

Been convicted of any offenses for which the aggregate
sentences were 5 or more years of cinfinement?
Yes
No

34.

Been ordered deported, excluded, or removed from the
United States as you were inadmissible at time of entry or
of adjustment of status, or violates status?

25.c. Intentionally and severely injuring any person?
Yes

No

25.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes

25.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes

No

No

Have you ever:

26.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
Yes
No

Yes

35.

Convicted a felony crime of violence that has an element
the use or attempted use of physical force against another
individual or may be used in the course of committing the
offense?
Yes
No

36.

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?

26.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No
27.

28.

29.

Been a member of, assisted in, or participated in any
group, unit or organization of any kind in which you or
other persons used any type of weapon against any person
or threatened to do so?
Yes
No
Assisted or participated in selling or providing weapons to
any person who to your knowledge used them against
another person, or in transporting weapons to any person
who to your knowledge used them against another
person?
Yes
No
Received any type of military, paramilitary, or weapons
training?
Yes
No

No

Yes
37.

Committed a serious nonpolitical crime outside the
United States before you arrived in the United States?
Yes

38.

No

No

Been convicted of a felony or 3 or more misdemeanors in
the United States?
Yes
No

NOTE: If you answer "Yes" to any of the questions above
(25.a. - 38.), provide a complete explanation on a separate sheet
of paper. Write your name and A-Number, if you have one, at
the top of each sheet, indicate the number of the question to
which your answer refers, sign, and date on each sheet.

Have you ever:
30.a. Engaged in, conspired to engage in, or intended to engage
in a terrorist activity with intent to cause death or serious
bodily harm?
Yes
No
30.b. 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

Form I-817 Instructions 09/18/12 N

Page 8 of 10

Part 5. Signature of Applicant (Read the
information on penalties in the instructions
before completing this section. You must file
this application while in the United States.)
Applicant's Statement (Choose one of the following):
1.a.

1.b.

Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

DRAFT Not
For Production
I can read and understand English, and I have read and
understand each and every question and instruction on
this form, as well as my answer to each question.
Each and every question and instruction on this form,
as well as my answer to each question, has been read
to me in the:

1.b.1.

3.c. City or Town
3.d. State
3.f.

3.e. Zip Code

Postal Code

3.g. Province
3.h. Country

language, a language in which I am fluent, by the
person named in Part 7, Interpreter's Statement
and Signature. I understand each and every
question and instruction on this form, as well as
my answer to each question.

I certify, under penalty of perjury under the laws of the United
States of America, that this application and the evidence
evidence submitted with it is all true and correct. I authorize
the release of any information from my records that U.S.
Citizenship and Immigration Services needs to determine
eligibility for the benefit I am seeking.
2.a. Signature of Applicant

2.b. Date of Signature (mm/dd/yyyy) ►

Preparer's Contact Information

4.

Daytime Phone Number (if any)

(

5.

)

Extension

-

E-Mail Address (If any)

Declaration

To be completed by all preparers, including attorneys and
authorized representatives: I declare that I prepared this benefit
request at the request of the applicant, that it is based on all the
information of which I have knowledge, and that the
information is true to the best of my knowledge.
6.a. Signature of Preparer

NOTE: If you do not completely fill out this form or fail to
submit required documents listed in the instructions, you may
not be found eligible for the requested benefit and this
application may be denied.

6.b. Date of Signature (mm/dd/yyyy) ►

Part 7. Interpreter's Statement and Signature
Part 6. Signature of Person Preparing This
Application, If Other Than the Applicant
NOTE: If you are an attorney or a BIA-accredited
representative, you must submit a completed Form G-28, Notice
of Entry of Appearance as Attorney or Accredited
Representative, along with this application.
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)

1.

Language Used

I certify that I am fluent in English and the above-mentioned
language. I further certify that I have read each and every
question and instruction on this form, as well as the answer to
each question, to this applicant in the above-mentioned
language, and the applicant has understood each and every
instruction and question on the form, as well as the answer to
each question.
2.a. Signature of Interpreter

1.b. Preparer's Given Name (First Name)
2.b. Date of Signature (mm/dd/yyyy) ►
2.

Preparer's Business or Organization Name

Form I-817 Instructions 09/18/12 N

Page 9 of 10

Part 7. Interpreter's Statement and Signature
(continued)
Provide the following information concerning the interpreter:
3.a. Interpreter's Family Name (Last Name)

DRAFT Not
For Production

3.b. Interpreter's Given Name (First Name)

4.

Interpreter's Business or Organization Name

Interpreter's Mailing Address
5.a. Street Number
and Name
5.b. Apt.

Ste.

Flr.

5.c. City or Town
5.d. State

5.e. Zip Code

5.f. Postal Code
5.g. Province
5.h. Country

Interpreter's Contact Information
6.

Daytime Phone Number (if any)

(
7.

)

Extension

-

E-Mail Address (If any)

Part 8. 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 Instructions 09/18/12 N

Page 10 of 10