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pdfApplication to Register Permanent Residence or Adjust Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-485
OMB No. 1615-0023
Expires 06/30/2015
For USCIS Use Only
Receipt
Preference Category
Action Block
Country Chargeable
Priority Date
DRAFT
NOT FOR
PRODUCTION
06/12/2015
Section of Law
Applicant Interviewed
Date of Initial Interview
Interview Waived
Form I-693 Received
INA 209
INA 249
INA 245(a)
Sec. 13, Act of 9/11/57
INA 245(i)
Cuban Adjustment Act
INA 245(m)
Other
Lawful Permanent Resident as of:
To be completed by an attorney or accredited representative (if any).
Select this box if
Form G-28 is
attached.
Volag Number
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS ELIS Account Number (if any)
► START HERE - Type or print in black ink.
NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, U.S. Citizenship and Immigration Services (USCIS) may deny your application.
Part 1. Information About You (Person applying for lawful permanent residence)
1.
Your Current Legal Name (do not provide a nickname)
Family Name (Last Name)
2.
Given Name (First Name)
Middle Name
Other Names You Have Used Since Birth (if applicable) (NOTE: Provide all the names you have ever used, including your
family name at birth, other legal names, nicknames, aliases, and assumed names in the space provided in Part 13. Additional
Information.)
Family Name (Last Name)
Given Name (First Name)
3.
Date of Birth (mm/dd/yyyy) (NOTE: In addition to providing your actual date of birth,
include any other dates of birth you have used in connection with any legal names or non-legal
names in the space provided in Part 13. Additional Information.)
4.
Gender
Male
Middle Name
5.
City or Town of Birth
7.
Country of Citizenship or Nationality
Female
6.
Country of Birth
8.
Alien Registration Number (A-Number) (if any) (NOTE: If you have EVER used other A-Numbers, include the additional
A-Numbers in the space provided in Part 13. Additional Information.)
► A-
Form I-485 10/08/13 N
Page 1 of 20
Part 1. Information About You (Person applying for lawful permanent residence) (continued)
9.
10. U.S. Social Security Number (if any)
USCIS ELIS Account Number (if any)
►
►
11. U.S. Mailing Address
In Care Of Name (if any)
Street Number and Name
Apt. Ste. Flr. Number
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City or Town
State
ZIP Code
12. Alternate and/or Safe Mailing Address
If you are applying based on the Violence Against Women Act (VAWA) or as a special immigrant juvenile, human trafficking
victim (T nonimmigrant), or crime victim (U nonimmigrant) and you do not want USCIS to send notices about this application to
your home, you may provide an alternative and/or safe mailing address.
In Care Of Name (if any)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
13. Passport or Travel Document
Number Used at Last Entry
14. Expiration Date of this Passport or
Travel Document (mm/dd/yyyy)
16. Nonimmigrant Visa Number From this Passport
(if any)
18. Date of Last Arrival or Entry
(mm/dd/yyyy)
ZIP Code
15. Country that Issued this Passport or Travel
Document
17. Place of Last Arrival or Entry into the United States
City or Town
19. Form I-94 Arrival-Departure
Record Number (if any)
State
20. Expiration Date of Authorized Stay
Shown on Form I-94 (mm/dd/yyyy)
►
21. In what immigration status did you last enter the United States? (for example, visitor, student, exchange visitor, temporary
worker, parole)
22. What is your current immigration status (if it has changed since entry)?
23. Provide your name exactly as it appears on your Form I-94 (if any)
Family Name (Last Name)
Form I-485 10/08/13 N
Given Name (First Name)
Middle Name
Page 2 of 20
Part 2. Application Type or Filing Category
NOTE: Attach a copy of the Form I-797 receipt or approval notice for the underlying petition or application, as appropriate.
1.
I am applying to register lawful permanent residence or adjust status to that of a lawful permanent resident based on the
following immigrant category (select only one box). (See Instruction Booklet for Filing Form I-485 and Supplement A
(Instruction Booklet) for detailed instructions.):
Family-Based
Person admitted to the United States
as a fiancé(e) or child of a fiancé(e)
of a U.S. citizen, Form I-129F
(K-1/K-2 Nonimmigrant)
Other relative of a U.S. citizen or relative of a
lawful permanent resident under the family-based
preference categories, Form I-130
Immediate relative
of a U.S. citizen,
Form I-130
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Widow or widower of a
U.S. citizen, Form I-360
VAWA self-petitioner, Form I-360
Employment-Based
Alien worker, Form I-140
Alien entrepreneur, Form I-526
Special Immigrant
Religious worker,
Form I-360
Special immigrant
juvenile, Form I-360
Panama Canal Zone
employee, Form I-360
Certain Armed Forces
member, Form I-360
Certain physician,
Form I-360
Certain Afghan or Iraqi
national, Form I-360
Certain international
broadcaster, Form I-360
Certain G-4 international organization employee or family member
or NATO-6 employee or family member, Form I-360
Certain employee or former employee of the
U.S. Government abroad, Form DS-1884
Human Trafficking Victim or Crime Victim
Human trafficking victim (T Nonimmigrant),
Form I-914 or qualifying relative, Form I-914A
Crime victim (U Nonimmigrant), Form I-918, Form I-918A, or
qualifying relative, Form I-929
Asylee or Refugee
Asylum status (INA section 208), Form I-589
Refugee status (INA section 207), Form I-590
Special Programs Based on Certain Public Laws
The Cuban
Adjustment
Act
The Cuban Adjustment
Act for battered
spouses and children
Former Soviet Union or Indochinese
Parolees (Lautenberg Parolees)
Dependent status under
the Haitian Refugee
Immigrant Fairness Act
Dependent status under the Haitian
Refugee Immigrant Fairness Act
for battered spouses and children
Diplomats or high ranking officials unable to return
home (Section 13 of the Act of September 11, 1957)
Additional Options
Diversity Visa
program
Continuous residence in the
United States since before
January 1, 1972 ("Registry")
Individuals born under
diplomatic status in the
United States
Private immigration
bill signed into law
Other eligibility (Explain):
2.
Are you applying for adjustment based on the Immigration and Nationality Act (INA) section 245(i)?
Yes
No
NOTE: If you answered "Yes" to Item Number 2., you must have selected a family-based, employment-based, special
immigrant, or Diversity Visa immigrant category listed above in Item Number 1. as the basis for your application for adjustment
of status. Fill out the rest of this application and Supplement A. For detailed filing instructions, read the Form I-485 Instructions,
Supplement A Instructions, and the Additional Information in this Instruction Booklet that relate to the immigrant category
that you selected in Item Number 1.
Form I-485 10/08/13 N
Page 3 of 20
Part 2. Application Type or Filing Category (continued)
Information About Principal Applicant
3.
If you are the principal applicant, provide the following information.
A. Receipt Number of Underlying Petition
(if any)
B. Priority Date from Underlying Petition
(if any) (mm/dd/yyyy)
►
Information About Derivative Applicant
4.
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If you are a derivative applicant (the spouse or unmarried child under 21 years of age of a principal applicant), provide the
following information.
A. Principal Applicant's Name
Family Name (Last Name)
B. Principal Applicant's A-Number
(if any)
► A-
Given Name (First Name)
C. Principal Applicant's Date of Birth
(mm/dd/yyyy)
D. Receipt Number of Principal's Underlying Petition
(if any)
►
Middle Name
E. Principal Applicant's Priority Date
(if any) (mm/dd/yyyy)
Part 3. Additional Information About Applicant
1.
Have you ever applied for an immigrant visa at a U.S. Embassy or U.S. Consulate abroad?
Yes
No
If you answered "Yes" to Item Number 1., complete Items A. - C. below.
A. Location of U.S. Embassy or U.S. Consulate
City
Country
B. Decision (for example, approved, refused, denied, withdrawn) C. Date of Decision (mm/dd/yyyy)
Address History
2.
Provide your physical addresses for the last five years, whether inside or outside the United States. Provide your current address
first. If you need extra space to complete this section, use the space provided in Part 13. Additional Information.
A. Physical Address 1 (current address)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Date of Residence From (mm/dd/yyyy)
Form I-485 10/08/13 N
Postal Code
ZIP Code
Country
To (mm/dd/yyyy)
Page 4 of 20
Part 3. Additional Information About Applicant (continued)
B. Physical Address 2
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Postal Code
Country
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Date of Residence From (mm/dd/yyyy)
3.
ZIP Code
To (mm/dd/yyyy)
Provide your most recent address outside the United States where you lived for more than one year (if not already listed above).
Street Number and Name
Apt. Ste. Flr. Number
City or Town
Province
Postal Code
Country
Date of Residence From (mm/dd/yyyy)
To (mm/dd/yyyy)
Employment History
4.
Provide your employment history for the last five years, whether inside or outside the United States. Provide the most recent
employment first. If you need extra space to complete this section, use the space provided in Part 13. Additional Information.
A. Employer 1 (current or most recent)
Name of Employer/Company
Address of Employer/Company
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Postal Code
ZIP Code
Country
Your Occupation
From (mm/dd/yyyy)
Form I-485 10/08/13 N
To (mm/dd/yyyy)
Page 5 of 20
Part 3. Additional Information About Applicant (continued)
B. Employer 2
Name of Employer/Company
Address of Employer/Company
Street Number and Name
Apt. Ste. Flr. Number
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City or Town
State
Province
Postal Code
ZIP Code
Country
Your Occupation
From (mm/dd/yyyy)
5.
To (mm/dd/yyyy)
Provide your most recent employment outside of the United States (if not already listed above)?
Name of Employer/Company
Address of Employer/Company
Street Number and Name
Apt. Ste. Flr. Number
City or Town
Province
Postal Code
Country
Your Occupation
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Part 4. Information About Your Parents
Information About Your Mother/Father/Parent
1.
What is your mother's/father's/parent's legal name?
A. Family Name (Last Name)
Given Name (First Name)
Middle Name
B. Family Name at Birth (Last Name, if different
than above)
Given Name (First Name)
Middle Name
C. Date of Birth (mm/dd/yyyy)
Form I-485 10/08/13 N
D. City or Town of Birth
Page 6 of 20
Part 4. Information About Your Parents
E. Country of Birth
F. Current City or Town of Residence (if living)
G. Current Country of Residence (if living)
Information About Your Mother/Father/Parent
2.
What is your mother's/father's/parent's legal name?
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A. Family Name (Last Name)
Given Name (First Name)
Middle Name
B. Family Name at Birth (Last Name, if different
Given Name (First Name)
than above)
Middle Name
C. Date of Birth (mm/dd/yyyy)
D. City or Town of Birth
E. Country of Birth
F. Current City or Town of Residence (if living)
G. Current Country of Residence (if living)
Part 5. Information About Your Marital History
1.
What is your current marital status?
Single, Never Married
Married
Divorced
Widowed
Marriage Annulled
Legally Separated
2.
If you are married, is your spouse a current member of the U.S. Armed Forces or U.S. Coast Guard?
3.
How many times have you been married (including annulled marriages and marriages to the same person)?
4.
Information About Your Current Marriage (including if you are legally separated)
Yes
No
If you are currently married, provide the following information about your current spouse.
A. Current Spouse's Legal Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
B. Current Spouse's Date of Birth (mm/dd/yyyy) C. Date of Marriage to Current Spouse (mm/dd/yyyy)
D. Current Spouse's Place of Birth (City or Town, State or Province, and Country)
City or Town
State or Province
Country
Form I-485 10/08/13 N
Page 7 of 20
Part 5. Information About Your Marital History (continued)
E. Place of Marriage to Current Spouse (City or Town, State or Province, and Country)
City or Town
State or Province
Country
5.
Is your current spouse applying with you?
6.
Information About Prior Marriages (if any)
Yes
No
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If you have been married before, whether in the United States or in any other country, provide the following information about
your prior spouse. If you have had more than one previous marriage, use the space provided in Part 13. Additional Information
to provide the information below.
A. Prior Spouse's Legal Name
Family Name (Last Name)
Given Name (First Name)
B. Prior Spouse's Date of Birth (mm/dd/yyyy)
Middle Name
C. Date of Marriage to Prior Spouse (mm/dd/yyyy)
D. Place of Marriage to Prior Spouse (City or Town, State or Province, and Country)
City or Town
State or Province
Country
E. Date Marriage with Prior Spouse Ended (mm/dd/yyyy)
F. Place Where Marriage with Prior Spouse Ended (City or Town, State or Province, and Country)
City or Town
State or Province
Country
Part 6. Information About Your Children
1.
Indicate the total number of children you have. (NOTE: Include all of your living children, including children of any age;
children born in the United States or in other countries; children who are currently married or unmarried; children living with you
or elsewhere; current stepchildren; legally adopted children; and children born when you were not married.)
Form I-485 10/08/13 N
Page 8 of 20
Part 6. Information About Your Children (continued)
2.
Provide the following information for each of your children. If you need extra space to complete this section, use the space
provided in Part 13. Additional Information.
A. Child 1
Current Legal Name
Family Name (Last Name)
Given Name (First Name)
A-Number (if any)
► A-
Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
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Is this child applying with you?
Yes
No
Yes
No
Yes
No
B. Child 2
Current Legal Name
Family Name (Last Name)
Given Name (First Name)
A-Number (if any)
► A-
Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Is this child applying with you?
C. Child 3
Current Legal Name
Family Name (Last Name)
Given Name (First Name)
A-Number (if any)
► A-
Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Is this child applying with you?
Part 7. Biographic Information
1.
Ethnicity (Select only one box)
Hispanic or Latino
2.
Not Hispanic or Latino
Race (Select all applicable boxes)
White
Asian
Black or African
American
3.
Height
Feet
4.
Weight
Pounds
5.
Eye Color (Select only one box)
Black
6.
American Indian or
Alaska Native
Native Hawaiian or
Other Pacific Islander
Inches
Blue
Brown
Gray
Green
Hazel
Maroon
Pink
Unknown/Other
Hair Color (Select only one box)
Bald (No
hair)
Form I-485 10/08/13 N
Black
Blond
Brown
Gray
Red
Sandy
White
Unknown/
Other
Page 9 of 20
Part 8. General Eligibility and Inadmissibility Grounds
1.
A. Have you EVER been a member of, involved in, or in any way associated with, any organization, association, fund,
foundation, party, club, society, or similar group in the United States or in any other location in the world including any
military service?
Yes
No
B. If you answered "Yes," provide the information below. If you need extra space to complete this section, use the space
provided in Part 13. Additional Information.
Name of Organization
Location
Nature of the Group
Dates of Involvement or
Membership
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From
To
(mm/dd/yyyy) (mm/dd/yyyy)
Answer Item Numbers 2. - 68. If you answer "Yes" to any questions, use the space provided in Part 13. Additional Information to
provide an explanation. Answering "Yes" does not necessarily mean that you are ineligible to adjust status or register lawful
permanent residence.
2.
Have you EVER been denied admission to the United States?
Yes
No
3.
Have you EVER been denied a visa to the United States?
Yes
No
4.
Have you EVER worked in the United States without authorization?
Yes
No
5.
Have you EVER violated the terms or conditions of your nonimmigrant status?
Yes
No
6.
Are you presently or have you EVER been in removal, exclusion, rescission, or deportation
proceedings?
Yes
No
7.
Have you EVER been issued a final order of exclusion, deportation, or removal?
Yes
No
8.
Have you EVER had a prior final order of exclusion, deportation, or removal reinstated?
Yes
No
9.
Have you EVER held lawful permanent resident status which was later rescinded?
Yes
No
10. Have you EVER been granted voluntary departure by an immigration officer or an
immigration judge but failed to depart within the allotted time?
Yes
No
11. Have you EVER applied for any kind of relief or protection from removal, exclusion, or
deportation?
Yes
No
12. A. Have you EVER been a J nonimmigrant exchange visitor who was subject to the two-year
foreign residence requirement?
Yes
No
B. Have you complied with the foreign residence requirement?
Yes
No
C. Have you been granted a waiver?
Yes
No
Yes
No
If you answered "Yes" to Item A. in Item Number 12., complete Items B. - C. If you answered
"No" to Item A. in Item Number 12., skip to Item Number 13.
Health
13. Have you EVER used any illegal drugs or abused any legal drugs?
Form I-485 10/08/13 N
Page 10 of 20
Part 8. General Eligibility and Inadmissibility Grounds (continued)
Criminal Acts and Violations
For Item Numbers 14. - 34., you must answer "Yes" to any question that applies to you, even if your records were sealed or otherwise
cleared, or if anyone, including a judge, law enforcement officer, or attorney, told you that you no longer have a record. You must
also answer "Yes" to the following questions whether the action or offense occurred here in the United States or anywhere else in the
world. If you answer "Yes" to Item Numbers 14. - 34., use the space provided in Part 13. Additional Information to provide an
explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged;
when (date) the event occurred; and the outcome or disposition (for example, no charges filed, charges dismissed, jail, probation,
community service.)
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14. Have you EVER been arrested, cited, charged, or detained for any reason by any law enforcement
official (including, but not limited to any U.S. immigration official or any official of the U.S.
Armed Forces or U.S. Coast Guard)?
Yes
No
15. Have you EVER committed a crime of any kind (even if you were not arrested, cited, charged
with, or tried for that crime)?
Yes
No
16. Have you EVER pled guilty to or been convicted of a crime or offense (even if the violation was
subsequently expunged or sealed by a court, or if you were granted a pardon, amnesty, a
rehabilitation decree, or other act of clemency)?
Yes
No
17. Have you EVER been ordered punished by a judge or had conditions imposed on you that
restrained your liberty (such as a prison sentence, suspended sentence, house arrest, parole,
alternative sentencing, drug or alcohol treatment, rehabilitative programs or classes, probation, or
community service)?
Yes
No
18. Have you EVER been in a criminal proceeding (including pre-trial diversion, deferred
prosecution, deferred adjudication, or any withheld adjudication)?
Yes
No
19. Have you EVER been involved in a controlled substance violation according to the laws and
regulations of any country?
Yes
No
20. Have you EVER been convicted of two or more offenses (other than purely political offenses)
for which the combined sentences to confinement were five years or more?
Yes
No
21. Have you EVER illicitly (illegally) trafficked or benefited from the trafficking of any controlled
substances, such as chemicals, illegal drugs, or narcotics?
Yes
No
22. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded in the illicit
trafficking of any illegal narcotic or other controlled substances?
Yes
No
23. Are you the spouse, son, or daughter of a foreign national who illicitly trafficked or aided (or
otherwise abetted, assisted, conspired, or colluded) in the illicit trafficking of a controlled
substance, such as chemicals, illegal drugs, or narcotics and you obtained, within the last five
years, any financial or other benefit from the illegal activity of your spouse or parent, although
you knew or reasonably should have known that the financial or other benefit resulted from the
illicit activity of your spouse or parent?
Yes
No
24. Have you EVER engaged in prostitution or are you coming to the United States to engage in
prostitution?
Yes
No
25. Have you EVER directly or indirectly procured (or attempted to procure) or imported prostitutes
or persons for the purpose of prostitution?
Yes
No
26. Have you EVER received any proceeds or money from prostitution?
Yes
No
NOTE: If you were the beneficiary of a pardon, amnesty, a rehabilitation decree, or other act of
clemency, provide documentation of that post-conviction action.
Form I-485 10/08/13 N
Page 11 of 20
Part 8. General Eligibility and Inadmissibility Grounds (continued)
27. Do you intend to engage in illegal gambling or any other form of commercialized vice, such as
prostitution, bootlegging, or sale of child pornography, while in the United States?
Yes
No
28. Have you EVER exercised immunity (diplomatic or otherwise) to avoid being prosecuted for a
criminal offense in the United States?
Yes
No
29. Have you EVER, while serving as a foreign government official, been responsible for or directly
carried out violations of religious freedoms?
Yes
No
30. Have you EVER induced by force, fraud, or coercion (or otherwise been involved in) the
trafficking of persons for commercial sex acts?
Yes
No
31. Have you EVER trafficked a person into involuntary servitude, peonage, debt bondage, or
slavery? Trafficking includes recruiting, harboring, transporting, providing, or obtaining a
person for labor or services through the use of force, fraud, or coercion.
Yes
No
32. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with others in
trafficking persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or
slavery?
Yes
No
33. Are you the spouse, son or daughter of a foreign national who engaged in the trafficking of
persons and have received or obtained, within the last five years, any financial or other benefits
from the illicit activity of your spouse or your parent, although you knew or reasonably should
have known that this benefit resulted from the illicit activity of your spouse or parent?
Yes
No
34. Have you EVER engaged in money laundering or have you EVER knowingly aided, assisted,
conspired, or colluded with others in money laundering or do you seek to enter the United States
to engage in such activity?
Yes
No
A. Engage in any activity that violates or evades any law relating to espionage (including
spying) or sabotage in the United States?
Yes
No
B. Engage in the United States in any activity that violates or evades any law prohibiting the
export from the United States of goods, technology, or sensitive information?
Yes
No
C. Engage in any other unlawful activity?
Yes
No
D. Engage in any activity whose purpose includes opposing, controlling, or overthrowing the
U.S. Government by force, violence, or other unlawful means while in the United States?
Yes
No
A. Committed, threatened to commit, attempted to commit, conspired to commit, incited,
endorsed, espoused, planned, or prepared any of the following: hijacking, sabotage,
kidnapping, political assassination, use of a weapon or explosive to endanger safety or cause
damage, or any other form of terrorist activity?
Yes
No
B. Been a member or a representative of an organization that did any of the above?
Yes
No
C. Received military-type training from an organization that did any of the above?
Yes
No
D. Solicited members, money, or things of value for an organization that did any of the above?
Yes
No
E. Provided material support for the commission of any of the activities identified above, for an
individual who commits any of the above activities, or for a group that did any of the above?
Yes
No
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Terrorist-Related and National Security
35. Do you intend to:
36. Have you EVER:
NOTE: If you answered "Yes," to any part of Item Number 36., explain what occurred, including the dates and location of the
circumstances in the space provided in Part 13. Additional Information.
Form I-485 10/08/13 N
Page 12 of 20
Part 8. General Eligibility and Inadmissibility Grounds (continued)
37. Do you intend to engage in any of the activities listed in Item Number 36.?
Yes
No
38. Are you the spouse or child of an individual who engaged in any of the activities listed in Item
Number 36.?
Yes
No
Yes
No
40. Have you EVER worked in any prison, jail, prison camp, detention facility, labor camp, or any
situation that involved detaining persons?
Yes
No
41. 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
42. Have you EVER 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,
insurgent organization, or any other group that engaged in armed combat?
Yes
No
43. Do you engage, or intend to engage upon your entry into the United States, in activity that could
have potentially serious adverse foreign policy consequences for the United States?
Yes
No
44. Have you EVER been a member of, or in any way affiliated with, the Communist Party or any
other totalitarian party (in the United States or abroad)?
Yes
No
45. During the period from March 23, 1933 to May 8, 1945, did you ever order, incite, assist, or
otherwise participate in the persecution of any person because of race, religion, national origin,
or political opinion, in association with either the Nazi government of Germany or any
organization or government associated or allied with the Nazi government of Germany?
Yes
No
NOTE: If you answered "Yes" to Item Number 38., explain the relationship, what occurred, including
the dates and location of the circumstances in the space provided in Part 13. Additional Information.
39. Have you EVER assisted or participated in selling, providing, or transporting weapons to any
person who you knew used them against another person?
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46. Have you EVER ordered, incited, called for, committed, assisted, or otherwise participated in any of the following:
A. Acts involving torture, genocide, or human trafficking?
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
(physically or under threat or duress) to participate?
Yes
No
E. Limiting or denying any person's ability to exercise religious beliefs?
Yes
No
A. Endanger the lives, property, or welfare of U.S. citizens?
Yes
No
B. Compromise the national defense of the United States?
Yes
No
C. Materially damage the foreign relations or economic interests of the United States?
Yes
No
48. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to
serve in or help an armed force or group?
Yes
No
49. Have you EVER 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
50. Have you received public assistance in the United States from any source, including the U.S.
Government or any state, country, city, or municipality (other than emergency medical treatment)?
Yes
No
51. Are you likely to receive public assistance in the future?
Yes
No
47. Do you act or intend to act in any way to endanger the security of the United States, such as to:
Public Charge
Form I-485 10/08/13 N
Page 13 of 20
Part 8. General Eligibility and Inadmissibility Grounds (continued)
Illegal Entries and Other Immigration Violations
52. Have you EVER failed or refused to attend or to remain in attendance at your removal,
exclusion, or deportation proceeding?
Yes
No
53. Have you EVER submitted fraudulent or counterfeit documentation to any U.S. Government
official to obtain or attempt to obtain any immigration benefit, including a visa or entry into the
United States?
Yes
No
54. Have you EVER lied about, concealed, or misrepresented any information on an application or
petition to obtain a visa, other documentation required for entry into the United States, admission
to the United States, or any other kind of immigration benefit?
Yes
No
55. Have you EVER falsely claimed to be a U.S. citizen (in writing or any other way)?
Yes
No
56. Have you EVER been a stowaway on a vessel or aircraft arriving in the United States?
Yes
No
57. Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to enter or
to try to enter the United States illegally (alien smuggling)?
Yes
No
58. Are you under a final order of civil penalty for violating INA section 274C for use of fraudulent
documents?
Yes
No
59. Have you EVER obtained a student nonimmigrant visa and violated the terms or conditions of
your student nonimmigrant status?
Yes
No
60. Have you ever been excluded, deported, or removed from the United States or have you ever
departed the United States on your own after having been ordered excluded, deported, or removed
from the United States?
Yes
No
61. Have you ever entered the United States without being inspected and admitted or paroled?
Yes
No
A. For more than 180 days, but less than a year and then departed the United States?
Yes
No
B. For one year or more and then departed the United States?
Yes
No
A. Having been unlawfully present in the United States for more than one year in the aggregate?
Yes
No
B. Having been deported, excluded, or removed from the United States?
Yes
No
64. Do you plan to practice polygamy in the United States?
Yes
No
65. Are you accompanying another foreign national who requires your protection or guardianship
but is inadmissible after being certified to be helpless under INA section 232(c)?
Yes
No
66. Have you EVER assisted in detaining, retaining, or withholding custody of a U.S. citizen child,
outside the United States, from a U.S. citizen who has been granted custody of the child?
Yes
No
67. Have you EVER voted in any federal, state, or local election in the United States?
Yes
No
68. Have you EVER renounced U.S. citizenship to avoid being taxed by the United States?
Yes
No
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Removal, Unlawful Presence, or Illegal Reentry After Previous Immigration Violations
62. Since April 1, 1997, have you been unlawfully present in the United States:
NOTE: You were unlawfully present in the United States if you entered the United States
without being inspected and admitted or paroled, or if you legally entered the United States but
you stayed longer than permitted.
63. Since April 1, 1997, have you EVER reentered or attempted to reenter the United States without
being inspected and admitted or paroled after:
Miscellaneous Conduct
Form I-485 10/08/13 N
Page 14 of 20
Part 9. Accommodations for Individuals With Disabilities and/or Impairments
NOTE: Read the Accommodations for Individuals With Disabilities and/or Impairments section of the Form I-485 Instructions
before completing this part.
1.
Are you requesting an accommodation because of your disabilities and/or impairments?
Yes
No
If you answered "Yes" to Item Number 1., select any applicable box.
A.
I am deaf or hard of hearing and request the following accommodation (if you are requesting a sign-language interpreter,
indicate for which language (for example, American Sign Language)):
B.
I am blind or have low vision and request the following accommodation:
C.
I have another type of disability and/or impairment (describe the nature of your disability and/or impairment and the
accommodation you are requesting):
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Part 10. Applicant's Statement, Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature
NOTE: Read the information on penalties in the Penalties section of the Form I-485 Instructions before completing this part. You
must file Form I-485 while in the United States.
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 11. 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 in Part 11. 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 Application Support Center (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
,
is not an attorney or accredited representative, preparing this application for me. This person who assisted
who
is
me in preparing my application has reviewed the Acknowledgement of Appointment at USCIS Application Support
Center with me and I understand the ASC Acknowledgement.
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
5.
Applicant's Email Address (if any)
Form I-485 10/08/13 N
4.
Applicant's Mobile Telephone Number (if any)
Page 15 of 20
Part 10. Applicant's Statement, Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, 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)
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Acknowledgement of Appointment at USCIS Application Support Center
I,
,
understand that the purpose of a USCIS ASC appointment is for me to provide fingerprints, photograph, and/or signature and to re-affirm
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 as identified by the
receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with my
application 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-affirming
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 that I seek.
I understand that if I am a male who is 18 to 26 years of age submitting this application will automatically register me with the
Selective Service System as required by the Military Selective Service Act.
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 and enforcement of U.S. immigration laws.
I certify, under penalty of perjury, that the information in my application, my responses to each question, 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)
NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, your application may be denied.
Form I-485 10/08/13 N
Page 16 of 20
Part 11. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
1.
Interpreter's Family Name (Last Name)
Interpreter's Given Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
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Interpreter's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
ZIP Code
Country
Postal Code
Interpreter's Contact Information
4.
Interpreter's Daytime Telephone Number
5.
Interpreter's Email Address (if any)
Interpreter's Certification
I certify that:
, which is the same language provided in Part 10.,
I am fluent in English and
Item B., in Item Number 1.; 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 10., Item B. in Item Number 1.;
I have read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant in the same language
provided in Part 10., 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, photograph, 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
Form I-485 10/08/13 N
Date of Signature (mm/dd/yyyy)
Page 17 of 20
Part 12. Contact Information, Statement, Certification, and Signature of the Person Who Prepared This
Application, If Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name
1.
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
2.
Preparer's Business or Organization Name (if any)
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Preparer's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Postal Code
ZIP Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
6.
Preparer's Email Address (if any)
5.
Preparer's Fax 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.
NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this
application, you must submit a completed Form G-28, Notice of Attorney or Accredited Representative, with 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 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-485 10/08/13 N
Date of Signature (mm/dd/yyyy)
Page 18 of 20
Part 13. 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) ► A-
3.
A. Page Number
D.
4.
5.
A. Page Number
D.
6.
Middle Name
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A. Page Number
D.
Given Name (First Name)
A. Page Number
B. Part Number
C. Item Number
B. Part Number
C. Item Number
B. Part Number
C. Item Number
B. Part Number
C. Item Number
D.
NOTE: Do not complete Part 14. until the USCIS Officer instructs you to do so at the interview.
Form I-485 10/08/13 N
Page 19 of 20
Part 14. Signature at Interview
I swear (affirm) and certify under penalty of perjury under the laws of the United States of America that I know that the contents of
this Form I-485, Application to Register Permanent Residence or Adjust Status, subscribed by me, including corrections number 1
through
, are complete, true, and correct. The evidence submitted by me on numbered pages 1 through
are complete, true, and correct.
Subscribed to and sworn to (affirmed) before me
USCIS Officer's Printed Name or Stamp
Date (mm/dd/yyyy)
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Applicant's Signature
Form I-485 10/08/13 N
USCIS Officer's Signature
Page 20 of 20
| File Type | application/pdf |
| File Title | Application to Register Permanent Residence or Adjust Status |
| Author | USCIS |
| File Modified | 2015-06-12 |
| File Created | 2015-06-12 |