Form I-485, Supplement I-485, Supplement Supplement A, Adjustment of Status to Permanent Resident

Supplement A, Adjustment of Status
to Permanent Resident Under INA Section 245(i)

USCIS
Form I-485

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

OMB No. 1615-0023
Expires 06/30/2015

NOTE: Use Form I-485 Supplement A, Adjustment of Status to Permanent Resident Under INA Section 245(i) (Supplement A), only
if you are applying to adjust status to that of a lawful permanent resident under the Immigration and Nationality Act (INA) section
245(i). You may file Supplement A only if you are filing your Form I-485, Application to Register Permanent Residence or Adjust
Status, at the same time or if you previously filed your Form I-485 and it remains pending.
►START HERE - Type or print in black ink.

Part 1. Information About You
1.

2.

3.

Your Current Legal Name
Family Name (Last Name)

Given Name (First Name)

Middle Name

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U.S. Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

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

4.

► A-

ZIP Code

USCIS ELIS Account Number (if any)
►

5.

Date of Birth (mm/dd/yyyy)

6.

7.

Country of Citizenship or Nationality

Country of Birth

Part 2. Eligibility
1.

Basis of INA section 245(i) Eligibility

You claim eligibility to adjust status under INA section 245(i) because (Select only one box):
A.

You are or were the principal beneficiary of an immigrant petition or application for permanent labor certification filed
on or before January 14, 1998.

B.

You are or were the principal beneficiary of an immigrant petition or application for permanent labor certification filed
on or after January 15, 1998, and on or before April 30, 2001, and you were physically present in the United States on
December 21, 2000.

C.

You are or were the derivative beneficiary of an immigrant petition or application for permanent labor certification
filed on or before January 14, 1998.

D.

You are or were the derivative beneficiary of an immigrant petition or application for permanent labor certification
filed on or after January 15, 1998, and on or before April 30, 2001, and the principal beneficiary was physically present
in the United States on December 21, 2000.

E.

You are currently the spouse or child (unmarried and under 21 years of age) applying to accompany or follow-to-join
your spouse or parent described in Items A., B., C., or D.

Form I-485 Supplement A 06/20/13 N

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Part 2. Eligibility (continued)
2.

Qualifying Petition or Application
Provide the following information about the immigrant petition or application for permanent labor certification filed on or before
April 30, 2001 that qualifies you to adjust status under INA section 245(i).
A. Receipt Number of Petition or Application (if any)

B. Name of Principal Beneficiary of Petition or Application
Family Name (Last Name)

3.

Given Name (First Name)

Middle Name

Immigrant Category

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Type or print the family-based, employment-based, special immigrant, or Diversity Visa immigrant category you selected on
Form I-485, Part 2. Application Type or Filing Category, Item Number 1.

Part 3. Bars to Adjustment
1.

You are applying to adjust under INA section 245(i) because one or more of the following bars to adjustment apply to you (Select
all applicable boxes):
A.

You last entered the United States without being admitted or paroled after inspection by an immigration officer.

B.

You last entered the United States as a nonimmigrant crewman.

C.

You are now employed or have ever been employed in the United States without authorization.

D.

You are not in lawful immigration status on the date of filing your application for adjustment of status.

E.

You have ever failed to continuously maintain a lawful status since entry into the United States, unless your failure to
maintain status was through no fault of your own or for technical reasons.

F.

You were last admitted to the United States in transit without a visa.

G.

You were last admitted to the United States as a nonimmigrant visitor without a visa under the Guam and
Commonwealth of the Northern Mariana Islands Visa Waiver Program, and you are not a Canadian citizen.

H.

You were last admitted to the United States as a nonimmigrant visitor without a visa under the Visa Waiver Program
(See travel.state.gov/content/visas/english/visit/visa-waiver-program.html).

I.

You are seeking employment-based adjustment of status and you are not maintaining a lawful nonimmigrant status on
the date of filing your application for adjustment of status.

J.

You have ever violated the terms of your nonimmigrant status.

Part 4. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the information on penalties in the Penalties section of the Supplement A Instructions before completing this part. You
must file Supplement A while in the United States.
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 supplement, as
well as my answer to every question.

Form I-485 Supplement A 06/20/13 N

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Part 4. Applicant's Statement, Contact Information, Certification, and Signature (continued)
B.

2.

The interpreter named in Part 5. has also read to me every question and instruction on this supplement, as well as my
answer to every question, in
, a language in which I am fluent.
I understand every question and instruction on this supplement as translated to me by my interpreter, and have provided
complete, true, and correct responses in the language indicated above.

Applicant's Statement Regarding the Preparer
,

I have requested the services of and consented to
who
is not an attorney or accredited representative, preparing this supplement for me.
is

Applicant's Contact Information

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3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

4.

Applicant's Mobile Telephone Number (if any)

Applicant's Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that U.S.
Citizenship and Immigration Services (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 furthermore authorize release of information contained in this supplement, 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 supplement and any document submitted with my supplement 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 supplement or fail to submit required documents listed in the
Instructions, USCIS may deny your Form I-485.

Part 5. 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)

2.

Interpreter's Business or Organization Name (if any)

Form I-485 Supplement A 06/20/13 N

Interpreter's Given Name (First Name)

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Part 5. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

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Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

Interpreter's Certification
I certify that:

I am fluent in English and
Item B. in Item Number 1.

, which is the same language provided in Part 4.,

I have read to this applicant every question and instruction on this supplement, as well as the answer to every question, in the language
provided in Part 4., Item B. in Item Number 1.; and
The applicant has informed me that he or she understands every instruction and question on the supplement, as well as the answer to
every question, and the applicant verified the accuracy of every answer.

Interpreter's Signature
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 6. Contact Information, Statement, Certification, and Signature of the Person Preparing This
Supplement, If Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Form I-485 Supplement A 06/20/13 N

Preparer's Given Name (First Name)

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Part 6. Contact Information, Statement, Certification, and Signature of the Person Preparing This
Supplement, If Other Than the Applicant (continued)
Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

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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 supplement 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 supplement.

NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this
supplement, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, with this supplement.

Preparer's Certification

By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this supplement on behalf of, at the request of,
and with the express consent of the applicant. I completed this supplement based only on responses the applicant provided to me.
After completing the supplement, I reviewed it and all of the applicant's responses with the applicant, who agreed with every answer
on the supplement. If the applicant supplied additional information concerning a question on the supplement, I recorded it on the
supplement.

Preparer's Signature
8.

Preparer's Signature

Form I-485 Supplement A 06/20/13 N

Date of Signature (mm/dd/yyyy)

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