Form I-687 Form I-687 Application for Status as a Temporary Resident Under Sec

Application for Status as a Temporary Resident Under Section 245A of the Immigration and Nationality Act

Form I-687

Application for Status as a Temporary Resident Under Section 245A of the Immigration and Nationality Act;

OMB: 1615-0090

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Form I-687, Application for Status as a
Temporary Resident Under Section 245A of the INA

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

Do not write in this block. For USCIS Use Only.
Action Block

Fee Stamp

Class of Admission

Waiver of Inadmissibility Under
Section 212(a)___________________
Approved
Denied

Applicant's A-Number

Place of Admission

Date of Adjustment

START HERE - Type or print in capital letters in black ink. (If you need more space, use a separate sheet of paper.)
1. I hereby apply for status as indicated by the block checked below:
A. Temporary Resident Status as an alien who illegally entered the U.S. prior to January 1, 1982.
B. Temporary Resident Status as an alien who entered the U.S. as a nonimmigrant prior to January 1, 1982, and whose
authorized stay expired before such date or whose unlawful status was known to the Government as of January 1, 1982.
2. Name
Family Name (Last Name)

Given Name (First Name)

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

Middle Name

4. Other A-Nos. and Names Used or Known By (including maiden name, if married) 5. Telephone Numbers (including area codes)
Home
Work
6. Home Address in the U.S.

U.S. Social Security No

In Care Of
Number and Street

Apt. No.

City

State

Zip Code

7. Mailing Address in the U.S. (if different from address in Number 6)
In Care Of
No. and Street Name

Apt. No.

City

State

Zip Code

8. Country of Citizenship
9. Place of Birth
City or Town

Country, Province, or State

Country

10. Marital Status
Now Married
11. Gender
Male
Female

Never Married

Separated

Divorced

Widowed

12. Race
Asian or Pacific Islander
Hispanic

Black, not of Hispanic origin
White, not of Hispanic origin

Other (specify below)

Form I-687 (02/07/13) Y

13. Have you previously applied for temporary residence as a Legalization applicant?
No
Yes
If Yes, give date, place of filing, and final disposition, if known.
14. Do you have other records with USCIS (or the former INS)?
No
Yes
If Yes, give file numbers. A-No.

Other

15. When did you first come to the U.S.?
(mm/dd/yyyy)

17. Place of first entry into U.S. to reside:

16. Manner of Entry
Without a visa

With a visa (visitor, student, etc.) specify:

Port of Entry (City and State):

Border - Not through a Port of Entry (State):
Living A No.

18. Mother's Name
(Maiden Name, Last Name, First Name)

Deceased (year)

Immigration Status

Living A No.

19. Father's Name
(Last Name, First Name)

Deceased (year)

Immigration Status

20. List your present and past husbands/wives and all of your sons and daughters (if additional space is needed, use separate paper).
Family Name

Given Name

Country of Birth
Family Name

Relationship
Given Name

Country of Birth
Family Name

Given Name

Given Name

Country of Birth

A-Number
Relationship

Given Name

Country of Birth
Family Name

A-Number
Relationship

Country of Birth
Family Name

A-Number
Relationship

Country of Birth
Family Name

A-Number

A-Number
Relationship

Given Name

A-Number
Relationship

Form I-687 (02/07/13) Y Page 2

If you were admitted as a nonimmigrant prior to January 1, 1982, complete Numbers 21 through 29. If not, leave blank and
go to Number 30.
21. Passport Number

22. Country that Issued Passport

24. Type of Visa Issued
(B-2, F-1, etc.)

25. Date Visa Issued
(mm/dd/yyyy)

23. Location Where Visa Issued (City and Country)

26. Authorized Stay in U.S.
Expired (mm/dd/yyyy)

27. Class of Admission (Student,
Visitor, etc.)

29. Was your status violation known to the
28. Did you violate your legal
Government prior to January 1, 1982?
status prior to January 1, 1982?
No

Yes

No

Yes

If Yes, how was
your status violation
known to the
Government?

30. RESIDENCES IN THE UNITED STATES:
List all of your residences in the United States since your first entry, beginning with your present address. If you need more space
to complete, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each
sheet of paper and indicate on the sheet that the information refers to Number 30.
Number and Street Name
Apt. No.
City

State

Zip Code

From (mm/yyyy)

Number and Street Name
City

Apt. No.
State

Zip Code

From (mm/yyyy)

Number and Street Name
City

State

Zip Code

From (mm/yyyy)

State

Zip Code

From (mm/yyyy)

State

Zip Code

From (mm/yyyy)

To (mm/yyyy)
Apt. No.

State

Zip Code

From (mm/yyyy)

Number and Street Name
City

To (mm/yyyy)
Apt. No.

Number and Street Name
City

To (mm/yyyy)
Apt. No.

Number and Street Name
City

To (mm/yyyy)
Apt. No.

Number and Street Name
City

To (mm/yyyy)

To (mm/yyyy)
Apt. No.

State

Zip Code

From (mm/yyyy)

To (mm/yyyy)

Form I-687 (02/07/13) Y Page 3

31. AFFILIATIONS OR ASSOCIATIONS: List all affiliations or associations, clubs, organizations, churches, unions, businesses,
etc. to which you belong or have belonged. If you need more space to complete, use a separate sheet of paper. Write your name
and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information
refers to Number 31.
Name of Organization

Location (City and State)

From (mm/yyyy)

To (mm/yyyy)

32. ABSENCES FROM THE UNITED STATES SINCE FIRST ENTRY: List most recent absence first and then all previous
absences dating back to your first entry. If you need more space to complete, use a separate sheet of paper. Write your name and
Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information
refers to Number 32.
From (mm/yyyy)

To (mm/yyyy)

Purpose of Trip

Country

Manner of Reentry
(type of visa, EWI)

Form I-687 (02/07/13) Y Page 4

33. EMPLOYMENT IN THE UNITED STATES SINCE FIRST ENTRY: Show most recent employment first and then all
previous employment dating back to your first entry. If none, write "None." If you need more space to complete, use a separate
sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and
indicate on the sheet that the information refers to Number 33.
Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State
Hourly Wage

Zip Code

Occupation
From (mm/yyyy)

To (mm/yyyy)

Form I-687 (02/07/13) Y Page 5

33. EMPLOYMENT IN THE UNITED STATES SINCE FIRST ENTRY (continued)
Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

State

Zip Code

Occupation
From (mm/yyyy)

Hourly Wage

To (mm/yyyy)

Full Name of Employer
Number and Street Name

Suite No.

City
Annual Wage

34.

State
Hourly Wage

Zip Code

Occupation
From (mm/yyyy)

To (mm/yyyy)

I have registered under the Military Selective Service Act. My Selective Service Number is:
Form I-687 (02/07/13) Y Page 6

I am a male over the age of 17 and under the age of 26 required to register under the Military Selective Service Act and have
not done so. I wish to register at this time. My SSS Form 1 is attached.
I am a male born after 1959 and over the age of 26 and cannot now register.
I am exempt from Selective Service Registration either because I am a female or I was born before 1960.
35. 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

36. Have you ever been treated for a mental disorder, drug addiction, or alcoholism?

Yes

No

37. Have you ever committed a crime or offense for which you were not arrested?

Yes

No

Have you ever been arrested, cited, or detained by any law enforcement
officer (including USCIS or former INS and military officers) for any reason?

Yes

No

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

Yes

No

Have you ever been convicted of a crime or offense?

Yes

No

Have you ever been in jail or prison?

Yes

No

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

Yes

No

Have you ever received a suspended sentence, been placed on probation, or been paroled?

Yes

No

If you answered "Yes" to any of Number 37, complete the following table. If you need more space to complete, use a separate
sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and
indicate on the sheet that the information refers to Number 37.
Why were you arrested, cited, detained,
or charged?

Date arrested, cited, Where were you arrested,
Outcome or disposition of the arrest,
detained, or charged cited, detained, or charged?
citation, detention, or charge
(mm/dd/yyyy)
(City, State, Country)

Attach all certified police reports, indictments, and certified court dispositions for any arrests, citations, detentions,
charges, or imprisonment.
Yes

No

Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in
such activities in the future?

Yes

No

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

Yes

No

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

Yes

No

38. Have you, or a dependent member of your immediate family, ever received public assistance from
any source, including, but not limited to, the United States Government, any state, county, city, or
municipality?
39. Have you ever:

Form I-687 (02/07/13) Y Page 7

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

Yes

No

Engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited
membership or funds for, or have you through any means ever 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

Been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?

Yes

No

Engaged in genocide, or otherwise ordered, incited, assisted, or otherwise participated in the killing of
any person because of race, religion, nationality, ethnic origin, or political opinion?

Yes

No

Been deported, excluded, or removed from the United States at government expense, or have you ever
been or are you now in exclusion, deportation, removal, or rescission proceedings?

Yes

No

Left the United States to avoid being drafted into the United States Armed Forces?

Yes

No

Been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement
and have not yet complied with that requirement or obtained a waiver?

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

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

Yes

No

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

Yes

No

43. Are you now withholding custody of a United States citizen child outside the United States from a
person granted custody of the child?

Yes

No

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

Yes

No

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

45. If your native alphabet is in other than Roman letters, write your name in your native alphabet.

46. Language of your native alphabet.

Form I-687 (02/07/13) Y Page 8

47. Signature and Certification of Applicant (Sign below)
I CERTIFY, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. I
hereby consent and authorize U.S. Citizenship and Immigration Services to verify the information provided and to conduct police,
welfare, and other record checks pertinent to this application.
Signature

Date (mm/dd/yyyy)

48. 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(s), and it is based on all information provided to me by the
person(s). I have not knowingly withheld any material information that would affect the outcome of this application.
Attorney or Representative Only: In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
Yes
No
Preparer's Signature
Print Preparer's Family Name (Last Name)

Date (mm/dd/yyyy)
Print Preparer's Given Name (First Name)

Print Preparer's Middle Name

Preparer's Firm Name (if applicable)
Preparer's Address
Daytime Phone Number (with area code)

Fax Number (with area code)

USCIS Account Number (if any)

E-mail Address (if any)

Form I-687 (02/07/13) Y Page 9


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