Form I-698 Application to Adjust Status from Temporary to Permanent

Application to Adjust Status From Temporary
to Permanent Resident (Under Section 245A of the INA)

USCIS
Form I-698

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

Applicant Interviewed
Date:
For
USCIS
Date of Adjustment
Use
Only
Date:

OMB No. 1615-0035
Expires: 03/31/2015

Action Block

Remarks

DRAFT
Not for
Reproduction
08/29/2014

► START HERE - Type or print in black ink.

Part 1. Information About You
1.

Full Legal Name

Family Name (Last Name)
2.

Given Name (First Name)

Middle Name

Name as it Appears on Your Employment Authorization Document (Form I-766)
A. Family Name (Last Name)

Given Name (First Name)

Middle Name

B. Provide the reason for a difference in the names, if any (marriage, divorce, etc.)
3.

4.

Any Other Names Used

A. Family Name (Last Name)

Given Name (First Name)

Middle Name

B. Family Name (Last Name)

Given Name (First Name)

Middle Name

A. If your native alphabet does not use Roman letters, type or print your name in your native alphabet.
Family Name (Last Name)

Given Name (First Name)

Middle Name

B. Language of Your Native Alphabet
5.

U.S. Mailing Address
In Care Of Name

6.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Is your current U.S. mailing address the same as your U.S. physical address?

ZIP Code
Yes

No

If you answered "No," provide your U.S. physical address in Item Number 7.
Form I-698 03/11/13 N

Page 1 of 9

Part 1. Information About You (continued)
7.

8.

A-

U.S. Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Alien Registration Number (A-Number) (if any)
► A-

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

City or Town

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

11. Gender

DRAFT
Not for
Reproduction
08/29/2014
Female

Male

12. Place of Birth

9.

ZIP Code

Province or Foreign State

13. Country of Citizenship or Nationality
16. Marital Status

Country

14. Mother's First Name

Single (Never Married)

Married

15. Father's First Name

Divorced or Separated

Widowed

17 List absences from the United States since becoming a temporary resident. List the most recent absence first. If you have a single
absence that exceeded 30 days or if the total of all of your absences exceeds 90 days, explain using the space provided in Part 8.
Additional Information or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of the
sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
Country

From
(mm/dd/yyyy)

Purpose of Trip

To
(mm/dd/yyyy)

Total Days
Absent

Part 2. Biographic Information
1.

Ethnicity (Select only one box)

2.

Race (Select all applicable boxes)
White

Asian

Black or African
American

3.

Height

5.

Eye Color (Select only one box)

6.

4.

Inches

Feet

Black

Hispanic or Latino

Blue

Brown

American Indian or
Alaska Native

Weight

Gray

Not Hispanic or Latino

Native Hawaiian or
Other Pacific Islander

Pounds

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald
(No Hair)

Form I-698 03/11/13 N

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/
Other

Page 2 of 9

Part 3. Eligibility Standards
1.

A-

You are required to have a minimal understanding of standard English and a knowledge and understanding of the history and
Government of the United States. Select the appropriate box in Item A. or B. below.
A. I will satisfy these requirements through:
An examination at the time of interview for lawful permanent residence; or
Satisfactory pursuit of a course of study recognized by the Secretary of Homeland Security (Secretary).
B. I have satisfied these requirements by:
Satisfactory pursuit of a course of study recognized by the Secretary (attach appropriate documentation); or
An exemption because I am 65 years of age or older, under 16 years of age, or I am physically unable to comply. (If you
are physically unable to comply, explain and attach relevant documentation.)

DRAFT
Not for
Reproduction
08/29/2014

Answer Item Numbers 2. - 29. If you answer “Yes” to any of the questions, provide a complete explanation using the space provided
in Part 8. Additional Information or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of
each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
Answering “Yes” does not necessarily mean that you are not entitled to adjust status or register for lawful permanent residence.
2.

Have you EVER assisted in the persecution of any person or persons on account of race, religion, political
opinion, nationality, or membership in a particular social group?

Yes

No

3.

Have you EVER been treated for a mental disorder, drug addiction, or alcoholism?

Yes

No

4.

Have you EVER committed a crime or offense for which you were not arrested?

Yes

No

5.

Have you EVER been arrested, cited, or detained by any law enforcement officer (including Immigration
and Customs Enforcement (ICE), Customs and Border Protection (CBP), former Immigration and
Naturalization Service (INS), and/or military officers) for any reason?

Yes

No

6.

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

Yes

No

7.

Have you EVER been convicted of a crime or offense?

Yes

No

8.

Have you EVER been in jail or prison?

Yes

No

9.

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

Yes

No

10. Have you EVER received a suspended sentence, been placed on probation, or been paroled?

Yes

No

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

Yes

No

B. If "Yes," provide the names of the recipients and their U.S. Social Security Numbers below.
Full Name of Recipient (Family Name, Given Name, Middle Name)

U.S. Social Security Number

12. Have you EVER:
A. Within the past 10 years been a prostitute, procured anyone for prostitution, or intend to engage in such
activities in the future?

Yes

No

B. Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?

Yes

No

C. Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States
illegally?

Yes

No

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

Yes

No

Form I-698 03/11/13 N

Page 3 of 9

Part 3. Eligibility Standards (continued)

A-

13. Have you EVER engaged in, conspired to engage in, do you intend to engage in, or have you EVER
solicited membership or funds for, or have you EVER through any means assisted or provided any type of
material support to any person or organization that has EVER engaged or conspired to engage in sabotage,
kidnapping, political assassination, hijacking, or any other form of terrorist activity?

Yes

No

A. Espionage?

Yes

No

B. Any activity, a purpose of which, is opposition to, or the control or overthrow of, the Government of
the United States, by force, violence, or other unlawful means?

Yes

No

C. Any activity to violate or evade any law prohibiting the export from the United States of goods,
technology, or sensitive information?

Yes

No

15. Have you EVER been a member of, or in any way affiliated with, a Communist Party or any other
totalitarian party?

Yes

No

16. Did you EVER, during the period from March 23, 1933 to May 8, 1945, in association with either the Nazi
Government of Germany or any organization or government associated or allied with the Nazi Government
of Germany, order, incite, assist, or otherwise participate in the persecution of any person because of race,
religion, national origin, or political opinion?

Yes

No

17. Have you EVER claimed to be a United States citizen in writing or any other way?

Yes

No

18. Have you EVER been deported from the United States, removed from the United States at government
expense, excluded within the past year, or are you NOW, or have you EVER been in exclusion,
deportation, removal, or rescission proceedings?

Yes

No

19. Are you NOW under a final order of civil penalty for violating section 274C of the Immigration and
Nationality Act (INA) for use of fraudulent documents or have you EVER, by fraud or willful
misrepresentation of a material fact, sought to procure or procured a visa, other documentation, entry into
the United States, or any immigration benefit?

Yes

No

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

Yes

No

21. Have you EVER been a J nonimmigrant exchange visitor who was subject to the 2-year foreign residence
requirement and have not yet complied with that requirement or obtained a waiver?

Yes

No

22. Are you NOW withholding custody of a U.S. citizen child outside the United States from a person granted
custody of the child?

Yes

No

23. Do you plan to practice polygamy in the United States?

Yes

No

14. Do you intend to engage in the United States in:

DRAFT
Not for
Reproduction
08/29/2014

24. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
A. Acts involving torture or genocide?

Yes

No

B. Killing any person?

Yes

No

C. Intentionally and severely injuring any person?

Yes

No

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

Yes

No

E. Limiting or denying any person's ability to exercise religious beliefs?

Yes

No

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, guerrilla group, militia, or insurgent organization?

Yes

No

B. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that
involved detaining persons?

Yes

No

25. Have you EVER:

Form I-698 03/11/13 N

Page 4 of 9

Part 3. Eligibility Standards (continued)

A-

26. Have you EVER 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

27. Have you EVER assisted or participated in selling, providing, or transporting weapons to any person who,
to your knowledge, used them against another person?

Yes

No

28. Have you EVER received any type of military, paramilitary or weapons training?

Yes

No

A. Recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed
force or group?

Yes

No

B. Used any person under 15 years of age to take part in hostilities, or to help or provide services to
people in combat?

Yes

No

29. Have you EVER:

DRAFT
Not for
Reproduction
08/29/2014

Part 4. Accommodations for Individuals With Disabilities and Impairments (Read the information in the
Form I-698 instructions before completing this part.)
1.

Are you requesting an accommodation because of your disabilities and/or impairments?

Yes

No

If you answered "Yes," select all applicable boxes.
A.

I am deaf or hard of hearing and request the following accommodations (if you are requesting a sign-language interpreter,
indicate for which language (e.g., American Sign Language)):

B.

I am blind or have low vision and request the following accommodations:

C.

I have another type of disability and/or impairment (describe the nature of your disabilities and/or impairments and the
accommodations you are requesting):

Part 5. Applicant's Statement, Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Applicant's Statement Regarding the Interpreter
A.

I can read and understand English, and have read and understand every question and instruction on this application, as
well as my answer to every question. I have read and understand the Acknowledgement of Appointment at USCIS
Application Support Center.

B.

The interpreter named in Part 6. has read to me every question and instruction on this application, as well as my
answer to every question, in
, a language in which I
am fluent. I understand every question and instruction on this application as translated to me by my interpreter, and have
provided complete, true, and correct responses in the language indicated above. The interpreter named Part 6. has also
read the Acknowledgement of Appointment at USCIS Application Support Center to me, in the language in which I
am fluent, and I understand this ASC Acknowledgement as read to me by my interpreter.

2.

Applicant's Statement Regarding the Preparer
I have requested the services of and consented to
who is
is not an attorney or accredited representative, preparing this application for me. This person who assisted
me in preparing my application has reviewed the Acknowledgement of Appointment at USCIS Application Support
Center with me and I understand the ASC Acknowledgement.

Form I-698 03/11/13 N

,

Page 5 of 9

Part 5. Applicant's Statement, Contact Information, ASC Acknowledgement, ACertification, and Signature (continued)
Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

4.

Applicant's Mobile Telephone Number (if any)

Acknowledgement of Appointment at USCIS Application Support Center

DRAFT
Not for
Reproduction
08/29/2014

I,
, understand that the purpose of a USCIS Application Support
Center (ASC) appointment is for me to provide fingerprints, photograph, and/or signature and to re-verify that all of the information in
my application is complete, true, and correct and was provided by me. I understand that I will sign my name to the following
declaration which USCIS will display to me at the time I provide my fingerprints, photograph, and/or signature during my ASC
appointment:
By signing here, I declare under penalty of perjury that I have reviewed and understand my application, petition, or request as
identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or
requests filed with my application, petition, or request that I (or my attorney or accredited representative) filed with USCIS,
and that all of the information in these materials is complete, true, and correct.
I also understand that when I sign my name, provide my fingerprints, and am photographed at the USCIS ASC, I will be re-verifying
that I willingly submit this application; I have reviewed the contents of this application; all of the information in my application and all
supporting documents submitted with my application were provided by me and are complete, true, and correct; and if I was assisted in
completing this application, the person assisting me also reviewed this Acknowledgement of Appointment at USCIS Application
Support Center with me.

Applicant's Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the administration of U.S. immigration laws.
I certify, under penalty of perjury, that the information in my application and any document submitted with my application were
provided by me and are complete, true, and correct.

Applicant's Signature
6.

Applicant's Signature

Date of Signature (mm/dd/yyyy)

Part 6. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
Provide the following information concerning the interpreter.
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Form I-698 03/11/13 N

Interpreter's Given Name (First Name)

Page 6 of 9

Part 6. Interpreter's Contact Information, Certification, and Signature
(continued)

A-

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

DRAFT
Not for
Reproduction
08/29/2014

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5. Interpreter's Email Address (if any)

Interpreter's Certification
I certify that:

I am fluent in English and
in Part 5., Item B. in Item Number 1.;

, which is the same language provided

I have read to this applicant every question and instruction on this application, as well as the answer to every question, in the language
provided in Part 5., Item B. in Item Number 1.; and
I have read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant in the same language
provided in Part 5., Item B. in Item Number 1.
The applicant has informed me that he or she understands every instruction and question on the application, as well as the answer to
every question, and the applicant verified the accuracy of every answer; and
The applicant has also informed me that he or she understands the ASC Acknowledgement and that by appearing for a USCIS ASC
biometric services appointment and providing his or her fingerprints, photographs, and/or signature, he or she is re-affirming that the
contents of this application and all supporting documentation are complete, true, and correct.

Interpreter's Signature
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 7. Contact Information, Statement, Certification, and Signature of the Person Preparing This
Application, If Other Than the Applicant
Preparer's Full Name
Provide the following information concerning the preparer.
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization (if any)

Form I-698 03/11/13 N

Preparer's Given Name (First Name)

Page 7 of 9

Part 7. Contact Information, Statement, Certification, and Signature of the
Person Preparing This Application, If Other Than the Applicant (continued)

A-

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

DRAFT
Not for
Reproduction
08/29/2014

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Fax Telephone Number

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant
and with the applicant's consent.

B.

I am an attorney or accredited representative and my representation of the applicant in this case
extends
does not extend beyond the preparation of this application.

Preparer's Certification

By my signature, I certify, swear or affirm, under penalty of perjury, that I prepared this application on behalf of, at the request of, and
with the express consent of, the applicant. I completed this application based only on responses the applicant provided to me. After
completing the application, I reviewed it and all of the applicant's responses with the applicant, who agreed with each and every
answer on the application. If the applicant supplied additional information concerning a question on the application, I recorded it on
the application. I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant
and the applicant has informed me that he or she understands the ASC Acknowledgement.

Preparer's Signature
8.

Preparer's Signature

Form I-698 03/11/13 N

Date of Signature (mm/dd/yyyy)

Page 8 of 9

Part 8. Additional Information
If you need extra space to provide any additional information within this application, use the space below. If you need more space
than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper.
Include your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to
which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any)

3.

A. Page Number
D.

4.

5.

A. Page Number
D.

6.

Middle Name

► AB. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

DRAFT
Not for
Reproduction
08/29/2014

A. Page Number
D.

Given Name (First Name)

A. Page Number
D.

7.

Applicant's Signature

Form I-698 03/11/13 N

Date of Signature (mm/dd/yyyy)

Page 9 of 9