Table of Changes (form)

FORM TABLE OF CHANGES

FORM I-817,

Application for Family Unity Benefits

OMB Number 1615-0005

9/24/2012

Reason for Revision: To incorporate the 2 column format to expedite application processing,

incorporate standard language in the instructions, and to clarify areas of the instructions.

LOCATION	CURRENT VERSION	PROPOSED VERSION AND LOCATION
Page 1, For USCIS Use Only	Returned Date Date Resubmitted Date Date Reloc Sent Date Date Reloc Rec’d Date Date Applicant Interviewed On …. To Be Completed by Attorney or Representative, if any…	Page 1, For USCIS Use Only Returned Resubmitted Relocated Received Sent Remarks Delete To Be Completed by an Attorney or BIA Accredited Representative, if any…
Page 1, Part 1	Family Name (Last Name) [Fillable Box] Given Name (First Name) [Fillable Box] Full Middle Name [Fillable Box] Date of Birth (mm/dd/yyyy) [Fillable Box] A-Number (if any) [Fillable Box] U.S. Social Security Number (if any) [Fillable Box] Gender [Check Box] Male [Check Box] Female Home Address: Street Number and Name ( include apartment number) [Fillable Box] City [Fillable Box] State [Fillable Box] Zip Code [Fillable Box] Mailing Address: (if different from home address) [Fillable Box] C/O (In care of) [Fillable Box] City [Fillable Box] State [Fillable Box] Zip Code [Fillable Box] Daytime Phone Number (include area code) [Fillable Box]	Page 1, Part 1. Information About You (Person Requesting Family Unity Benefits) 1. Alien Registration Number (A-Number) A-[Fillable Box] 2.a. Family Name (Last Name) [Fillable Box] 2.b. Given Name (First Name) [Fillable Box] 2.c. Full Middle Name [Fillable Box] Other Names Used (Including Maiden Name) 3.a. Family Name (Last Name) [Fillable Box] 3.b. Given Name (First Name) [Fillable Box] 3.c. Full Middle Name [Fillable Box] _________________________________ 4.a. Family Name (Last Name) [Fillable Box] 4.b. Given Name (First Name) [Fillable Box] 4.c. Full Middle Name [Fillable Box] 5. Date of Birth (mm/dd/yyyy) [Fillable Box] 6. U.S. Social Security Number (If any) [Fillable Box] 7. Gender (Check the appropriate box) __Male __ Female 8. Country of Birth [Fillable Box] 9. Country of Citizenship [Fillable Box] Physical Address 10.a. Street Number and Name [Fillable Box] 10.b. Apt. __ Ste. __ Flr.__ 10.c. City or Town [Fillable Box] 10.d. State [Fillable Box] 10.e. Zip Code [Fillable Box] Mailing Address 11.a. In Care of Name [Fillable Box] 11.b. Street Number and Name [Fillable Box] 11.c. Apt. __ Ste. __ Flr.__ 11.d. City or Town [Fillable Box] 11.e State [Fillable Box] 11.f. Zip Code [Fillable Box] 12. Daytime Phone Number (If any) [Fillable Box] Extension [Fillable Box] 13. E-Mail Address (If any) [Fillable Box]
Page 1, Part 2	1. I am applying for family unity benefits because: (Check one box) A. [ ] 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. B. [ ] 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. C. [ ] 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. D. [ ] 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. E. 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. F. [ ] 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. G. [ ] 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. H. [ ] 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.	Page 2, Part 2. Basis For Application 1. I am applying for Family Unity benefits because: (Select only one box) a. [ ] On May 5, 1988, I was the spouse of an alien who was legalized under section 245A of the INA. 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; 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; 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); f. [ ] On May 5, 1988, I was the unmarried child under age 21 and the following apply: (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) ( (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 (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/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. . NOTE: To be eligible for IMMACT 90 Family Unity Program Benefits, your qualifying spouse or parent must have maintained his/her status as a legalized alien and as a U.S. citizen, if he/she naturalized. If deceased, status must have been maintained until his/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.
Page 2, Basis for Application	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.	Page 2, 2. I am requesting: (Select only one box) a. [ ] Initial Family Unity Benefits under section 301 of IMMACT 90. b. [ ] An extension of Family Unity Benefits under section 301 of IMMACT 90. c. [ ] Initial Family Unity Benefits under section 1504 of P.L. 106-554, the LIFE Act Amendments. d. [ ] An extension of Family Unity Benefits under section 1504 of P.L. 106-554, the LIFE Act Amendments.
Page 2, Basis for Application	3. I am claiming relationship to: (Check one box)…	Page 2, 3. I am claiming relationship to: (Select only one box)…
Page 2, Part 3. Additional Information	At the time of your last entry into the United States, you: __ were inspected and admitted __ were inspected and paroled __ entered without inspection Date of last arrival (mm/dd/yyyy) ____ I-94, Arrival-Departure Document No.__________________ Current or most recent immigration status______________________ Date status expires (mm/dd/yyyy)___________________ Date continuous U.S. residence began__________________________ 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_______________ Zip Code____________ Have you ever applied before for the Family Unity Program? __No __ Yes (If “Yes,” provide the following information) Name under which you applied:_________________________ City and state where application was filed____________________________ Date filed (mm/dd/yyyy)____________ USCIS action taken on case: __Approved __ Denied If separate applications for family unity benefits are being submitted at this time for other relatives, give the following information: (6 row table follows with the following data collections) Family Name (Last Name)_________ First Name______________________ Middle Name____________________ Relationship_____________________ A-Number______________________ List all other names you have used including maiden name._____________ 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)_______ Date of Departure (mm/dd/yyyy)_____ Date of Return (mm/dd/yyyy)_______ Date of Departure (mm/dd/yyyy)_____ Date of Return (mm/dd/yyyy)_______ 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.	Page 5, … … 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) [Fillable Box] 2.b. Given Name (First Name) [Fillable Box] 2.c. Full Middle Name [Fillable box] 2.d. City or Town Where Application Was Filed [Fillable Box] 2.e. State [Fillable box] 2.f. Date Filed (mm/dd/yyyy) [Fillable Box] 2.g. USCIS (or former INS) action taken on case [ ] Approved [ ] Denied 3.a. At the time of your last entry into the United States, you: [ ] Were inspected and admitted [ ] Were inspected and paroled [ ] Entered without inspection 3.b. Date of Last Arrival (mm/dd/yyyy) [Fillable Box] 3.c. Form I-94, Arrival-Departure Record Number [Fillable Box] 3.d. Passport Number [Fillable Box] 3.e.Travel Document Number [Fillable Box] 3.f. Country of Issuance for Passport or Travel Document [Fillable Box] 3.g. Expiration Date for Passport or Travel Document [Fillable Box] 3.h. Current or Most Recent Immigration Status [Fillable Box] 3.i. Date Status Expires (mm/dd/yyyy) [Fillable Box] 3.j. Date Continuous U.S. Residence Began (mm/dd/yyyy) [Fillable Box] Provide the U.S. address where you lived on May 5, 1988 (245A or Cuban Haitian Adjustment) or December 1, 1988 (sec. 210 or LIFE Act). 4.a. Street Number and Name [Fillable Box] 4.b. Apt. __ Ste.__ Flr.__ [Fillable Boxes] 4.c. City or Town [Fillable Box] 4.d. State [Fillable Box] 4.e. Zip Code [Fillable Box] 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) [Fillable Box] 5.b. Given Name (First Name) [Fillable Box] 5.c. Full Middle Name(s) [Fillable Box] 5.d. A-Number (if any) A-[Fillable Box] 5.e. Relationship to Applicant [Fillable Box] ___________________________________ 6.a. Family Name (Last Name) [Fillable Box] 6.b. Given Name (First Name) [Fillable Box] 6.c. Full Middle Name(s) [Fillable Box] 6.d. A-Number (if any) A-[Fillable Box] 6.e. Relationship to Applicant [Fillable Box] ___________________________________ 7.a. Family Name (Last Name) [Fillable Box] 7.b. Given Name (First Name) [Fillable Box] 7.c. Full Middle Name(s) [Fillable Box] 7.d. A-Number (if any) A-[Fillable Box] 7.e. Relationship to Applicant [Fillable Box] ___________________________________ 8.a. Family Name (Last Name) [Fillable Box] 8.b. Given Name (First Name) [Fillable Box] 8.c. Full Middle Name(s) [Fillable Box] 8.d. A-Number (if any) A-[Fillable Box] 8.e. Relationship to Applicant [Fillable Box] ___________________________________ 9.a. Family Name (Last Name) [Fillable Box] 9.b. Given Name (First Name) [Fillable Box] 9.c. Full Middle Name(s) [Fillable Box] 9.d. A-Number (if any) A-[Fillable Box] 9.e. Relationship to Applicant [Fillable Box] ____________________________________ 10.a. Family Name (Last Name) [Fillable Box] 10.b. Given Name (First Name) [Fillable Box] 10.c. Full Middle Name(s) [Fillable Box] 10.d. A-Number (if any) A-[Fillable Box] 10.e. Relationship to Applicant [Fillable Box] ____________________________________ 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. 11.a. Departure Date (mm/dd/yyyy) [Fillable Box] 11.b. Return Date (mm/dd/yyyy) [Fillable Box] ___________________________________ 12.a. Departure Date (mm/dd/yyyy) [Fillable Box] 12.b. Return Date (mm/dd/yyyy) [Fillable Box] 13.a. Departure Date (mm/dd/yyyy) [Fillable Box] 13.b. Return Date (mm/dd/yyyy) [Fillable Box] _________________________________ 14.a. Departure Date (mm/dd/yyyy) [Fillable Box] 14.b. Return Date (mm/dd/yyyy) [Fillable Box] __________________________________ 15.a. Departure Date (mm/dd/yyyy) [Fillable Box] 15.b. Return Date (mm/dd/yyyy) [Fillable Box] _________________________________ 16.a. Departure Date (mm/dd/yyyy) [Fillable Box] 16.b. Return Date (mm/dd/yyyy) [Fillable Box] _________________________________ 17.a. Departure Date (mm/dd/yyyy) [Fillable Box] 17.b. Return Date (mm/dd/yyyy) [Fillable Box]
Page 3, Part 3. Additional Information	List all the 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. (Table has 6 rows to capture information.) Street Number and Name (Including Apartment #) City State Zip Code Dates or Residence From: To:	Page 7., Part 4. Additional Information (continued) 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. Current Residence 18.a.Street Number and Name [Fillable Box] 18.b. Apt.__ Ste.__ Flr.__ 18.c. City or Town [Fillable Box] 18.d. State [Fillable Box] 18.e. Zip Code [Fillable Box] 18.f Dates of Residence (mm/dd/yyyy) From: [Fillable Box] To: PRESENT [Fillable Box] Previous Residence 1 19.a.Street Number and Name [Fillable Box] 19.b. Apt.__ Ste.__ Flr.__ 19.c. City or Town [Fillable Box] 19.d. State [Fillable Box] 19.e. Zip Code [Fillable Box] 19.f Dates of Residence (mm/dd/yyyy) From: [6 Fillable Boxes] To: Previous Residence 2 20.a.Street Number and Name [Fillable Box] 20.b. Apt.__ Ste.__ Flr.__ 20.c. City or Town [Fillable Box] 20.d. State [Fillable Box] 20.e. Zip Code [Fillable Box] 20.f Dates of Residence (mm/dd/yyyy) From: [Fillable Box] To: Previous Residence 3 21.a.Street Number and Name [Fillable Box] 21.b. Apt.__ Ste.__ Flr.__ 21.c. City or Town [Fillable Box] 21.d. State [Fillable Box] 21.e. Zip Code [Fillable Box] 21.f Dates of Residence (mm/dd/yyyy) From: [Fillable Box] To: Previous Residence 4 22.a.Street Number and Name [Fillable Box] 22.b. Apt.__ Ste.__ Flr.__ 22.c. City or Town [Fillable Box] 22.d. State [Fillable Box] 22.e. Zip Code [Fillable Box] 22.f Dates of Residence (mm/dd/yyyy) From: [Fillable Box] To: Previous Residence 5 23.a.Street Number and Name [Fillable Box] 23.b. Apt.__ Ste.__ Flr.__ 23.c. City or Town [Fillable Box] 23.d. State [Fillable Box] 23.e. Zip Code [Fillable Box] 23.f Dates of Residence (mm/dd/yyyy) From: [6 Fillable Boxes] To: Previous Residence 6 24.a.Street Number and Name [Fillable Box] 24.b. Apt.__ Ste.__ Flr.__ 24.c. City [Fillable Box] 24.d. State [Fillable Box] 24.e. Zip Code [Fillable Box] 24.f Dates of Residence (mm/dd/yyyy) From: [Fillable Box] 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.
Page 3-4, Part 3. Additional Information Questions 8-36	8. Do you have or have you ever had: a. communicable disease of public health significance (including chancroid, gonorrhea, granuloma inguinal, human immunodeficiency virus (HIV) infection, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, or active tuberculosis)? …	Page 8. Part 4. Additional Information All questions in this section have been renumbered (25.a.-38.) and many have been switched around. In addition, there are several new questions. The following questions are new: Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: 25.a. Acts involving torture or genocide? __ Yes __ No 25.b. Killing any person? __ Yes __ No 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 __ No 25.e. Limiting or denying any person’s ability to exercise religious beliefs? __ Yes __ No Have you ever: 26.a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerilla group, militia, or insurgent organization? __ Yes __ No 26.b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? __ Yes __ No 27. 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 28. 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 29. Received any type of military, paramilitary, or weapons training? __ Yes __ No Have you ever: 30a. 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 30b. 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 Have you ever 31. 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 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 confinement? __ 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? __ Yes __ No 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? __ Yes __ No 37. Committed a serious nonpolitical crime outside the United States before you arrived in the United States? __ Yes __ No 38. 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.
Page 5, Part 4. Information About Your Spouse or Parent (Your spouse or parent must be wither a legalized alien or an alien eligible for adjustment pursuant to the LIFE Act)	Provide the following information about the alien through wholm you are claiming your eligibility. Family Name (Last Name) [Fillable Box] Given Name (First Name) [Fillable Box] Full Middle Name [Fillable Box] Date of Birth (mm/dd/yyyy) [Fillable Box] A-Number (if any) [Fillable Box] U.S. Social Security Number (if any) [Fillable Box] Class of Admission [Fillable Box] Gender __ Male __ Female Home Address: Street Number and Name (include apartment number) [Fillable Box] City [Fillable Box] State [Fillable Box] Zip Code [Fillable Box] Daytime Phone No. (Area Code) [Fillable Box] List all other names used, including maiden name. [Fillable Box]	Page 2, Part 3. Information About Relationship Information About Your Spouse or Parent Provide the following information about the alien through whom you are claiming your eligibility. Spouse or Parent Information 1.a. Family Name (Last Name) [Fillable Box] 1.b. Given Name (First Name) [Fillable Box] 1.c. Full Middle Name [Fillable Box] 1.d. Date of Birth (mm/dd/yyyy) [Fillable Box] 1.e. A-Number (if any) [Fillable Box] 1.f. U.S. Social Security Number (if any) [Fillable Box] 1.g. Gender [Check Box] Male [Check Box] Female 1.h. Class of Admission (visitor, student, EWI, etc.) [Fillable Box] Physical Address in U.S. 2.a. Street Number and Name [Fillable Box] 2.b. Apartment Number [Fillable Box] 2.c. City or Town [Fillable Box] 2.d. State [Fillable Box] 2.e. Zip Code [Fillable Box] Contact Information 3. Daytime Phone Number (if any) [Fillable Box] Extension [Fillable Box] 4. E-Mail Address (If any) [Fillable Box] Other Names Used (Including maiden name) 5.a. Family Name (Last Name) [Fillable Box] 5.b. Given Name (First Name) [Fillable Box] 5.c. Full Middle Name [Fillable Box] __________________________________ 6.a. Family Name (Last Name) [Fillable Box] 6.b. Given Name (First Name) [Fillable Box] 6.c. Full Middle Name [Fillable Box] B. Complete If You Are Applying Based on a Marital Relationship or You Were Previously Married Provide the following information about your marital status Marital Status [ ] Single (never married) [ ] Married [ ] Divorced [ ] Widowed [ ] Separated Provide the following information about you and your spouse: 2.a. Number of times you have been married (including current marriage) [Fillable Box] 2.b. Number of times your spouse has been married (including current marriage) [Fillable Box] Provide the following information about your current marriage (if married). 3.a. Date of Marriage (mm/dd/yyyy) [Fillable Box] 3.b. Place of Marriage (City or Town) [Fillable Box] 3.c. State [Fillable Box] 3.d. Province [Fillable Box] 3.e. Country [Fillable Box] 3.f. Type of ceremony [ ] Religious [ ] Civil [ ] None 3.g. We are [ ] Living together [ ] Not living together 3.h. If you checked “Not living together," (select one): [ ] My spouse has died [ ] We are divorced [ ] We are separated Provide the following information about your prior marriages (if any). Prior Marriage Information 4.a. Family Name (Last Name) [Fillable Box] 4.b. Given Name (First Name) [Fillable Box] 4.c. Full Middle Name [Fillable Box] 5.a. Date of Marriage (mm/dd/yyyy) [Fillable Box] 5.b. Place of Marriage (City or Town) [Fillable Box] 5.c. State [Fillable Box] 5.d. Province [Fillable Box] 5.e. Country [Fillable Box] 5.f. Date of Termination (mm/dd/yyyy) [Fillable Box] 5.g. Place of Termination (City or Town) [Fillable Box] 5.h. State [Fillable Box] 5.i. Province [Fillable Box] 5.j. Country [Fillable Box] 5.k. Reason for Termination [ ] Divorce [ ] Death [ ] Annulment [ ] Other (Provide an explanation if there are any other reasons for termination): [Fillable Box] Provide the following information about YOUR SPOUSE’S prior marriages (if any). Your Spouse’s Prior Spouses Information 6.a. Family Name (Last Name) [Fillable Box] 6.b. Given Name (First Name) [Fillable Box] 6.c. Full Middle Name [Fillable Box] 7.a. Date of Marriage (if any)(mm/dd/yyyy) [Fillable Box] 7.b. Place of Marriage (City or Town) [Fillable Box] 7.c. State [Fillable Box] 7.d. Province [Fillable Box] 7.e. Country [Fillable Box] 7.f. Date of Termination (mm/dd/yyyy) [Fillable Box] 7.g. Place of Termination (City or Town) [Fillable Box] 7.h. State [Fillable Box] 7.i. Province [Fillable Box] 7.j. Country [Fillable Box] 7.k. Reason for Termination [ ] Divorce [ ] Death [ ] Annulment [ ] Other (Explain): [Fillable Box] 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 [ ] Stepparent - based on marriage to my parent which occurred before my 18th birthday [ ] Adoptive parent (select one): a. The adoption occurred before my 16th birthday [ ] Yes [ ] No 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 two years prior to that date . [ ] Yes [ ] No [ ] 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. Marital Status [ ] Single (never married) [ ] Married [ ] Divorced [ ] Widowed [ ] Separated Provide the following information 3.a. Date of Marriage (mm/dd/yyyy) [Fillable Box] 3.b. Place of marriage (City/Town) [Fillable Box] 3.c. State [Fillable Box] 3.d. Province [Fillable Box] 3.e. Country [Fillable Box] 3.f. Type of ceremony. [ ] Religious [ ] Civil [ ] None 3.g. We are [ ] Living together [ ] Not living together C. Complete Only If You Are Applying Based on a Child/Parent Relationship (continued) 3.h. If you checked "Not living together," (select one): [ ] My spouse has died [ ] We are divorced [ ] We are separated Provide the following information if divorced or widowed: 3.i. Date marriage ended (mm/dd/yyyy) [Fillable Box] 3.j. Place marriage ended (City or Town) [Fillable Box] 3.k. State [Fillable Box] 3.l. Province [Fillable Box] 3.m. Country [Fillable Box] NOTE: If you were previously married, go to 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 that 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)
Page 5, Part 5. Complete Only If You Are Applying Based on a Marital Relationship	Provide the following information about you and your spouse. Number of times you have been married. [Fillable Box] Number of times your spouse has been married[Fillable Box] Provide the following information about your current marriage. Date of marriage (mm/dd/yyyy) [Fillable Box] Place of marriage (City, State or province, and country) [Fillable Box] Type of ceremony. __ Religious __Civil __None We are: __ Living together __ Not living together	This section has been relocated to be on Page 3 of the revised form, Part 3, Information About Relationship, Section B., Complete If You Are Applying Based on a Marital Relationship or You Were Previously Married. See above.
Page 5, Part 6. Complete Only If You Are Applying Based on a Child/Parent Relationship	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: The adoption occurred before my 16th birthday My adoptive parent had legal custody of me for at least two years prior to May 5, 1988 or December 1, 1988, as appropriate I lived with my adoptive parent for at least two years prior to May 5, 1988 or December 1, 1988, as appropriate __ Parent based on circumstances not described above (Explain in detail on a separate sheet of paper.) Give the following information about your marital status. __ Single __ Married __Divorced __ Widowed 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)_____________ Type of ceremony. __Religious __Civil __None We are: __ Living together __ Not living together If divorced or widowed: Date marriage ended (mm/dd/yyyy)___ Place marriage ended (City, State or province, and country)_____________	This information has been incorporated in to Part 3, section C., of the revised form, on page 4. See section above.
Page 6, 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 [Fillable Box] Date (mm/dd/yyyy) [Fillable Box]	Page 9, Part 5. Signature of Applicant (Read the information on penalties in the Form I-817 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. [ ] 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. 1.b. [ ] 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 _______________________________ 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 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) [Fillable Box] 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.
Page 6, Part 8	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 [Fillable Box] Date (mm/dd/yyyy) [Fillable Box] Preparer’s Printed Name [Fillable Box] Preparer’s Firm Name (if applicable) [Fillable Box] Preparer’s Address [Fillable Box] Daytime Phone Number (with area code) [Fillable Box] Fax Number [Fillable Box] E-Mail Address (if any) [Fillable Box]	Page 9, 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) [Fillable Box] 1.b. Preparer’s Given Name (First Name) [Fillable Box] 2. Preparer’s Business or Organization Name [Fillable Box] Preparer’s Mailing Address 3.a. Street Number and Name [Fillable Box] 3.b. Apt.__ Ste.__ Flr.__ 3.c. City or Town [Fillable Box] 3.d. State [Fillable Box] 3.e. Zip Code [Fillable Box] 3.f. State [Fillable Box] 3.g. Province [Fillable Box] 3.h. Country [Fillable Box] 4. Daytime Phone Number (if any) [Fillable Box] Extension[Fillable Box] 5. E-Mail Address (If any) [Fillable Box] 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 [Fillable Box] 6.b. Date of Signature (mm/dd/yyyy) [Fillable Box]
		New Part 7. Interpreter's Statement and Signature 1. Language Used [Fillable Box] 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’s [Fillable Box] 2.b. Date of Signature (mm/dd/yyyy) [Fillable Box] Provide the following information concerning the interpreter: 3.a. Interpreter’s Family Name (Last Name) [Fillable Box] 3.b. Interpreter’s Given Name (First Name) [Fillable Box] 4. Interpreter’s Business or Organization [Fillable Box] Interpreter’s Mailing Address 5.a. Street Number and Name [Fillable Box] 5.b. Apt.__ Ste.__ Flr.__ 5.c. City or Town [Fillable Box] 5.d. State [Fillable Box] 5.e. Zip Code [Fillable Box] 5.f. State [Fillable Box] 5.g. Province [Fillable Box] 5.h. Country [Fillable Box] Interpreter’s Contact Information 6. Daytime Phone Number (if any) [Fillable Box] Extension[Fillable Box] 7. E-Mail Address (If any) [Fillable Box]
Page 6	Signature for Placement On Employment Authorization Document….	Page 10, Part 8, Signature for Placement On Employment Authorization Document….

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