Table of Changes - form

TABLE OF CHANGES – FORM

Form I-817, Application for Family Unity Benefits

OMB Number: 1615-0005

09/14/2015

Reason for Revision: Form I-817 and instructions were amended to include USCIS ELIS Account Number fields for electronic filing, to better serve the customers, and to improve USCIS operations al efficiency. Form I-817 was revised to include Postal Code, Province, and Country fields under Part 3. Additional Information to allow the affected party to file the form abroad. Standard language and formatting updates were also made.

Current Section and Page Number	Current Text	Proposed Text
Page 1, To Be Completed by an Attorney or a BIA- Accredited Representative, if any.	To Be Completed by an Attorney or a BIA- Accredited Representative, if any. Fill in box if G-28 is attached to represent the applicant. Attorney State License Number:	[Page 1] To be completed by an attorney or BIA accredited representative (if any). Select this box if Form G-28 is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS ELIS Account Number (if any)
Page 1-2, Part 1. Information About You (Person Requesting Family Unity Benefits)	[Page 1] Part 1. Information About You (Person Requesting Family Unity Benefits) 1. Alien Registration Number (A-Number) 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Full Middle Name Other Names Used (Including maiden name) 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Full Middle Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Full Middle Name Other Information 5. Date of Birth (mm/dd/yyyy) 6. U.S. Social Security Number (if any) 7. Gender (Check the appropriate box) Male Female 8. Country of Birth 9. Country of Citizenship Mailing Address 11.a. In Care of Name 11.b. Street Number and Name 11.c. Apt. Ste. Flr. 11.d. City or Town 11.e. State 11.f. Zip Code Physical Address 10.a. Street Number and Name 10.b. Apt. Ste. Flr. 10.c. City or Town 10.d. State 10.e. Zip Code [Page 2] Contact Information 12. Daytime Telephone Number (if any) Extension 13. E-mail Address (if any)	[Page 1] NOTE: You must reside and file Form I-817 while in the United States. Part 1. Information About You (Person Requesting Family Unity Benefits) 1. Alien Registration Number (A-Number) (if any) Your Full Name 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Other Names Used Provide any other names you have used since birth, including maiden names, and nicknames. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Information 5. Date of Birth (mm/dd/yyyy) 6. U.S. Social Security Number (if any) 7. USCIS ELIS Account Number (if any) 8. Gender Male Female 9. Country of Birth 10. Country of Citizenship or Nationality U.S. Mailing Address 11.a. In Care of Name 11.b. Street Number and Name 11.c. Apt. Ste. Flr. 11.d. City or Town 11.e. State 11.f. ZIP Code U.S. Physical Address 12.a. Street Number and Name 12.b. Apt. Ste. Flr. 12.c. City or Town 12.d. State 12.e. ZIP Code [Deleted] [Page 2] Biographic Information 13.  Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 14.  Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 15.  Height  Feet Inches 16.  Weight    Pounds 17.  Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 18.  Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Page 2, Part 2. Basis For Application	[Page 2] Part 2. Basis For Application (Select only one box) 1. I am applying for Family Unity benefits because: 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: 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); 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 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 or 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 or her status as a legalized alien or as a U.S. citizen, if he or she naturalized. If deceased, status must have been maintained until his or 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. 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. 3. I am claiming relationship to: (Select only one box) a. A legalized alien under section 301 of IMMACT 90. b. An alien who is eligible for and has filed for adjustment, or adjusted status under section 1504 of P.L. 106-554, the LIFE Act Amendments.	[Page 2] Part 2. Basis For Application I am applying for Family Unity benefits because: (Select only one box) 1.a. On May 5, 1988, I was the spouse of an alien who was legalized under section 245A of the Immigration Nationality Act (INA). 1.b. On May 5, 1988, I was the unmarried child under 21 years of age of an alien who was legalized under section 245A of the INA. 1.c. 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. 1.d. On December 1, 1988, I was the unmarried child under 21 years of age of an alien who was a legalized alien as a Special Agricultural Worker under section 210 of the INA. 1.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). 1.f. On May 5, 1988, I was the unmarried child under 21 years of age of a person who adjusted status under section 202 of the Immigration Reform and Control Act of 1986 (Cuban/Haitian Adjustment). [Deleted] 1.g. I am the spouse of a person who is eligible for and filed or adjusted status under section 1104 of Public Law (P. L.) 106-5534, the Legal Immigration Family Equality (LIFE) Act. I entered the United States on or before December 1, 1988 and resided in the United States on that date. 1.h. I am the unmarried child under 21 years of age of a person who had filed an adjustment of status application or adjusted status under section 1104 of P. L. 106-5534, the LIFE Act. I entered the United States on or before December 1, 1988, and resided in the United Stated on that date. NOTE: To be eligible for Immigration Act of 1990 (IMMACT 90) Family Unity Program benefits, your qualifying spouse or parent must have maintained his or her status as a legalized alien or as a U.S. citizen, if he or she naturalized. If deceased, he or she must have maintained status until his or her death. For LIFE Act Family Unity, your spouse or parent must be eligible for adjustment or have adjusted status under section 1104 of the LIFE Act. If you previously qualified for LIFE Act Family Unity, you may be eligible to apply for IMMACT 90 Family Unity Program Benefits. I am requesting: (Select only one box) 2.a. Initial Family Unity benefits under section 301 of IMMACT 90. 2.b. An extension of Family Unity benefits under section 301 of IMMACT 90. 2.c. Initial Family Unity benefits under section 1504 of the LIFE Act Amendments. 2.d. An extension of Family Unity benefits under section 1504 of the LIFE Act Amendments. [Deleted]
Page 2-5, Part 3. Information About Relationship	[Page 2] Part 3. Information About Relationship A. Information About Your Spouse or Parent Provide the following information about the alien through whom you are claiming your eligibility. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Full Middle Name [Page 3] Other Names Used (Including maiden name) 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Full Middle Name 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Full Middle Name [Page 2] 1.d. Date of Birth (mm/dd/yyyy) 1.e. A-Number (if any) 1.f. U.S. Social Security Number (if any) 1.g. Gender 1.h. Class of Admission (visitor, student, EWI, etc.) [Page 3] Physical Address in U.S. 2.a. Street Number and Name 2.b. Apt. Ste. Flr. 2.c. City or Town 2.d. State 2.e. Zip Code 3. Daytime Phone Number (if any) Ext. 4. E-mail Address (If any) B. Complete If You Are Applying Based on a Marital Relationship or You Were Previously Married 1. 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) 2.b. Number of times your spouse has been married (including spouse current marriage) Provide the following information about your current marriage (if married) 3.a. Date of Marriage (mm/dd/yyyy) 3.b. Place of Marriage (City or Town) 3.c. State 3.d. Province 3.e. Country 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 Prior Marriage Information Provide the following information about your prior marriages (if any) 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Full Middle Name 5.a. Date of Marriage (mm/dd/yyyy) (if married) 5.b. Place of Prior Marriage (City or Town) 5.c. State 5.d. Province 5.e. Country 5.f. Date of Termination (mm/dd/yyyy) 5.g. Place of Termination (City or Town) [Page 4] 5.h. State 5.i. Province 5.j. Country 5.k. Reason for Termination Divorce/Death/Annulment/ Other (Provide an explanation if there are any other reasons for termination): Your Spouse’s Prior Spouse’s Information Provide the following information about YOUR SPOUSE'S prior marriages (if any). 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Full Middle Name 7.a. Date of Marriage (mm/dd/yyyy) (if any) 7.b. Place of Prior Marriage (City or Town) 7.c. State 7.d. Province 7.e. Country 7.f. Date of Termination (mm/dd/yyyy) 7.g. Place of Termination (City or Town) 7.h. State 7.i. Province 7.j. Country 7.k. Reason for Termination Divorce/Death/Annulment/ Other (Provide an explanation if there are any other reasons for termination): NOTE: If you were previously married, you must complete 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 it has been completed. 4. I have completed Part., Section B., Item Numbers 1. – 7.k., information about my prior marriage(s) (if any). [Page 5] C. Complete Only If You Are Applying Based on a Child/Parent Relationship 1. Indicate how your parent if 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): The adoption occurred before my 16th birthday; 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 2 years to that date. 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) 3.b. Place of Marriage (City or Town) 3.c. State 3.d. Province 3.e. Country 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 if divorced or widowed: 3.i. Date Marriage Ended (mm/dd/yyyy) 3.j. Place Marriage Ended (City or Town) 3.k. State 3.l. Province 3.m. Country	[Page 3] Part 3. Information About Your Relationship If you need extra space to complete Part 3., use the space provided in Part 9. Additional Information. Information About Your Spouse or Parent Provide the following information about the legalized alien through whom you are claiming your eligibility. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Other Names Used (Including maiden name, nicknames, etc.) 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. Date of Birth (mm/dd/yyyy) 5. A-Number (if any) 6. USCIS ELIS Account Number (if any) 7. U.S. Social Security Number (if any) 8. Gender 9. Class of Admission (visitor, student, EWI, etc.) U.S. Physical Address for Your Spouse or Parent 10.a. Street Number and Name 10.b. Apt. Ste. Flr. 10.c. City or Town 10.d. State 10.e. ZIP Code 11. Daytime Telephone Number 12. Email Address (if any) Complete Only If You Are Applying Based on a Marital Relationship or You Were Previously Married 13. Marital Status [Deleted] Married Divorced Widowed Separated Provide the following information about you and your spouse. 14.a. Number of times you have been married (including current marriage) 14.b. Number of times your spouse has been married (including spouse’s current marriage) If currently married, provide the following information about your marriage 15.a. Date of Marriage (mm/dd/yyyy) Place of Marriage 15.b. City or Town 15.c. State 15.d. Province 15.e. Country 15.f. Type of Ceremony Religious/Civil/None 15.g. We are Living together/Not living together 15.h. If you selected "Not living together," (Select only one box) My spouse has died We are divorced We are separated Information About Your Prior Marriage Provide the following information about your prior marriages (if any) 16.a. Family Name (Last Name) 16.b. Given Name (First Name) 16.c. Middle Name [Page 4] 17.a. Date of Marriage (mm/dd/yyyy) (if any) Place of Prior Marriage 17.b. City or Town 17.c. State 17.d. Province 17.e. Country 17.f. Date of Termination (mm/dd/yyyy) Place of Termination 17.g. City or Town 17.h. State 17.i. Province 17.j. Country 17.k. Reason for Termination Divorce/Death/Annulment/ Other (Provide an explanation if there are any other reasons for termination. If you need extra space to provide an explanation, use the space provided in Part 9. Additional Information.) Information About Your Spouse’s Prior Spouse Provide the following information about your current spouse’s prior marriages (if any). 18.a. Family Name (Last Name) 18.b. Given Name (First Name) 18.c. Middle Name 19.a. Date of Marriage (mm/dd/yyyy) (if any) Place of Prior Marriage 19.b. City or Town 19.c. State 19.d. Province 19.e. Country 19.f. Date of Termination (mm/dd/yyyy) Place of Termination 19.g. City or Town 19.h. State 19.i. Province 19.j. Country 19.k. Reason for Termination Divorce/Death/Annulment/ Other (Provide an explanation if there are any other reasons for termination. If you need extra space to provide an explanation, use the space provided in Part 9. Additional Information.) NOTE: If you were previously married, you must complete Part 3., Item Numbers 13. – 19.k. of this application; complete all requested information about your prior marriages; and select the box in Item Number 20. indicating that it is complete. 20. I have completed Part 3., Item Numbers 13. – 19.k., information about my prior marriages (if any). Complete Only If You Are Applying Based on a Child/Parent Relationship Indicate how your parent if related to you (Select only one box) 21.a. Biological mother 21.b. Biological father who was married to my mother when I was born 21.c. Biological father who was not married to my mother when I was born 21.d. Stepparent - based on marriage to my parent which occurred before my 18th birthday 21.e. Adoptive parent (Select only one box): A. The adoption occurred before my 16th birthday. 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. [Deleted] [Page 5] Provide the following information about your marital status. 22.a. Marital Status Single, Never Married Married Divorced Widowed Separated Provide the following information. 23.a. Date of Marriage (mm/dd/yyyy) Place of Marriage 23.b. City or Town 23.c. State 23.d. Province 23.e. Country 23.f. Type of Ceremony Religious/Civil/None 23.g. We are Living together Not living together 23.h. If you selected "Not living together," (Select only one box) My spouse has died We are divorced We are separated If divorced or widowed, provide the following information. 24.a. Date Marriage Ended (mm/dd/yyyy) Place of Marriage 24.b. City or Town 24.c. State 24.d. Province 24.e. Country
Page 5-8, Part 4. Additional Information	[Page 5] Part 4. Additional Information 1. Have you ever applied before for the Family Unity Program? (If "Yes," provide the following information) Name Under Which You Applied 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Full Middle Name 2.d. City or Town Where Application Was Flied 2.e. State 2.f. Date Filed (mm/dd/yyyy) 2.g. USCIS (or former INS) action taken on case 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) 3.c. Form I-94, Arrival-Departure Record Number 3.g. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 3.i. Date Status Expires (mm/dd/yyyy) 3.j. Date Continuous U.S. Residence Began (mm/dd/yyyy) Provide the U.S. address where you lived on May 5, 1988 (245Aor or Cuban Haitian Adjustment) or December 1, 1988 (section 210 or LIFE Act). 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.e. Zip Code If separate applications for Family Unity benefits are being submitted at this time for other relatives, provide the following information: 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. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Full Middle Name 5.d. A-Number (if any) 5.e. Relationship to Applicant [Page 6] 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Full Middle Name 6.d. A-Number (if any) 6.e. Relationship to Applicant 7.a. Family Name (Last Name) 7.b. Given Name (First Name) 7.c. Full Middle Name 7.d. A-Number (if any) 7.e. Relationship to Applicant 8.a. Family Name (Last Name) 8.b. Given Name (First Name) 8.c. Full Middle Name 8.d. A-Number (if any) 8.e. Relationship to Applicant 9.a. Family Name (Last Name) 9.b. Given Name (First Name) 9.c. Full Middle Name 9.d. A-Number (if any) 9.e. Relationship to Applicant 10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Full Middle Name 10.d. A-Number (if any) 10.e. Relationship to Applicant 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) 11.b. Return Date (mm/dd/yyyy) 12.a. Departure Date (mm/dd/yyyy) 12.b. Return Date (mm/dd/yyyy) 13.a. Departure Date (mm/dd/yyyy) 13.b. Return Date (mm/dd/yyyy) 14.a. Departure Date (mm/dd/yyyy) 14.b. Return Date (mm/dd/yyyy) 15.a. Departure Date (mm/dd/yyyy) 15.b. Return Date (mm/dd/yyyy) 16.a. Departure Date (mm/dd/yyyy) 16.b. Return Date (mm/dd/yyyy) 17.a. Departure Date (mm/dd/yyyy) 17.b. Return Date (mm/dd/yyyy) [Page 7] 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 18.b. Apt. Ste. Flr. 18.c. City or Town 18.d. State 18.e. Zip Code 18.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 1 19.a. Street Number and Name 19.b. Apt. Ste. Flr. 19.c. City or Town 19.d. State 19.e. Zip Code 19.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 2 20.a. Street Number and Name 20.b. Apt. Ste. Flr. 20.c. City or Town 20.d. State 20.e. Zip Code 20.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 3 21.a. Street Number and Name 21.b. Apt. Ste. Flr. 21.c. City or Town 21.d. State 21.e. Zip Code 21.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 4 22.a. Street Number and Name 22.b. Apt. Ste. Flr. 22.c. City or Town 22.d. State 22.e. Zip Code 22.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 5 23.a. Street Number and Name 23.b. Apt. Ste. Flr. 23.c. City or Town 23.d. State 23.e. Zip Code 23.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 6 24.a. Street Number and Name 24.b. Apt. Ste. Flr. 24.c. City or Town 24.d. State 24.e. Zip Code 24.f. Dates of Residence (mm/dd/yyyy) From To 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 8] Answer the following questions: 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? 25.b. Killing any person? 25.c. Intentionally and severely injuring any person? 25.d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? 25.e. Limiting or denying any person's ability to exercise religious beliefs? 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? 26.b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? 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? 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? 29. Received any type of military, paramilitary, or weapons training? Have you ever: 30.a. Engaged in, conspired to engage in, or intended to engage in a terrorist activity with intent to cause death or serious bodily harm? 30.b. Been a representative of a terrorist organization or a member of an organization which you knew or should have known is terrorist organization? 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? 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? 33. Been convicted of any offenses for which the aggregate sentences were 5 or more years of confinement? 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? 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? 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? 37. Committed a serious nonpolitical crime outside the United States before you arrived in the United States? 38. Been convicted of a felony or 3 or more misdemeanors in the United States?	[Page 5] Part 4. Other Information 1. Have you EVER applied before for the Family Unity Program? If you answered "Yes," provide the following information. Name Under Which You Applied 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Place Where Application Was Filed 2.d. City or Town 2.e. State 2.f. Date Filed (mm/dd/yyyy) 2.g. U.S. Citizenship and Immigration Services (USCIS) (or former Immigration and Naturalization Service (INS)) action taken on case 3.a. At the time of your last entry into the United States, you (Select only one box) Were inspected and admitted Were inspected and paroled Entered without inspection 3.b. Date of Last Arrival (mm/dd/yyyy) 3.c. Form I-94 Arrival-Departure Record Number 3.g. Expiration Date for Passport or Travel Document (mm/dd/yyyy) 3.i. Date Status Expires (mm/dd/yyyy) 3.j. Date Continuous U.S. Residence Began (mm/dd/yyyy) [Page 6] Provide the U.S. address where you lived on May 5, 1988 (INA 245Aor or Cuban Haitian Adjustment Act) or December 1, 1988 (INA section 210 or LIFE Act). 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.e. ZIP Code If you are submitting separate applications for Family Unity benefits at this time for other relatives, provide the following information about those other relatives. NOTE: If you need more space to complete an answer in Item Numbers 5.a. - 24.f., use Part 9. Additional Information. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 5.d. A-Number (if any) 5.e. Relationship to Applicant 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name 6.d. A-Number (if any) 6.e. Relationship to Applicant 7.a. Family Name (Last Name) 7.b. Given Name (First Name) 7.c. Middle Name 7.d. A-Number (if any) 7.e. Relationship to Applicant 8.a. Family Name (Last Name) 8.b. Given Name (First Name) 8.c. Middle Name 8.d. A-Number (if any) 8.e. Relationship to Applicant 9.a. Family Name (Last Name) 9.b. Given Name (First Name) 9.c. Middle Name 9.d. A-Number (if any) 9.e. Relationship to Applicant [Page 7] 10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name 10.d. A-Number (if any) 10.e. Relationship to Applicant List all absences from the United States since May 5, 1988 or December 1, 1988, as appropriate to the section of law that applies to you, or since the approval of your last Form I-817, whichever date is later. [No change] [Page 7] List all residences in the United States since May 5, 1988 or December 1, 1988, as appropriate to the section of law that applies to you, or since the approval of your last Form I-817, whichever date is later. Current Residence 18.a. Street Number and Name 18.b. Apt. Ste. Flr. 18.c. City or Town 18.d. State 18.e. ZIP Code 18.f. Dates of Residence (mm/dd/yyyy) From To Present Previous Residence 1 19.a. Street Number and Name 19.b. Apt. Ste. Flr. 19.c. City or Town 19.d. State 19.e. ZIP Code 19.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 2 20.a. Street Number and Name 20.b. Apt. Ste. Flr. 20.c. City or Town 20.d. State 20.e. ZIP Code 20.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 3 21.a. Street Number and Name 21.b. Apt. Ste. Flr. 21.c. City or Town 21.d. State 21.e. ZIP Code 21.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 4 22.a. Street Number and Name 22.b. Apt. Ste. Flr. 22.c. City or Town 22.d. State 22.e. ZIP Code 22.f. Dates of Residence (mm/dd/yyyy) From To Previous Residence 5 23.a. Street Number and Name 23.b. Apt. Ste. Flr. 23.c. City or Town 23.d. State 23.e. ZIP Code 23.f. Dates of Residence (mm/dd/yyyy) From To [Page 8] Previous Residence 6 24.a. Street Number and Name 24.b. Apt. Ste. Flr. 24.c. City or Town 24.d. State 24.e. ZIP Code 24.f. Dates of Residence (mm/dd/yyyy) From To If you answer “Yes” to any of the questions in Item Numbers 25.a. – 38., use the space provided in Part 9. Additional Information to provide an explanation. 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? 25.b. Killing any person? 25.c. Intentionally and severely injuring any person? 25.d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? 25.e. Limiting or denying any person's ability to exercise religious beliefs? 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? 26.b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? 27. 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? 28. Have you EVER 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? 29. Have you EVER received any type of military, paramilitary, or weapons training? Have you EVER in the United States or Abroad: 30.a. Engaged in, conspired to engage in, or intended to engage in a terrorist activity with intent to cause death or serious bodily harm? 30.b. Been a representative of a terrorist organization or a member of an organization which you knew or should have known is terrorist organization? 31. Have you EVER engaged in 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? Have you EVER: 32.a. Been convicted by a final judgment of a particularly serious crime? 32.b. Participated in any other criminal activity which endangers public safety or national security of the United States? 33. Have you EVER been convicted of any offenses for which the aggregate sentences were five or more years of confinement? 34. Have you EVER been ordered deported, excluded, or removed from the United States as you were inadmissible at the time of entry or of adjustment of status, or violated status? 35. Have you EVER been convicted of a felony crime of violence that has an element of or attempted use of physical force against another individual in the course of committing the offense? 36. Have you EVER 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? [Page 9] 37. Have you EVER committed a serious nonpolitical crime outside the United States before you arrived in the United States? 38. Have you EVER been convicted of a felony or three or more misdemeanors in the United States?
Page 9, Part 5. Signature of Applicant (Read the information on penalties in the instructions before completing this section. You must file this application while in the United States.)	Part 5. Signature of Applicant (Read the information on penalties in the 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. [Fillable Field] 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 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) 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 9] Part 5. 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-817 Instructions before completing this part. Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.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. 1.b. The interpreter named in Part 6. has also read to me every question and instruction on this application, as well as my answer to every question, in [Fillable Field], 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 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 Application Support Center (ASC) Acknowledgement as read to me by my interpreter. 2. I have requested the services of and consented to [Fillable Field], 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. Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone (if any) 5. Applicant’s Email Address (if any) Acknowledgement of Appointment at USCIS Application Support Center I, [Fillable Field], understand that the purpose of a USCIS ASC appointment is for me to provide my 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, 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-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. [Page 10] 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 furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS record 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 and any document submitted with my application were provided by me and are complete, true, and correct. Applicant’s Signature 6.a. Applicant’s Signature 6.b. 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, USCIS may deny your application.
Page 9-10, Part 7. Interpreter's Statement and Signature	[Page 10] Part 7. Interpreter's Statement and Signature Provide the following information concerning the interpreter: 3.a. Interpreter's Family Name (Last Name) 3.b. Interpreter's Given Name (First Name) 4. Interpreter's Business or Organization Name Interpreter's Mailing Address 5.a. Street Number and Name 5.b. Apt. Ste. Flr. 5.c. City or Town 5.d. State 5.e. Zip Code 5.f. Postal Code 5.g. Province 5.h. Country Interpreter's Contact Information 6. Daytime Phone Number (if any) Extension 7. E-Mail Address (If any) [Page 9] 1. Language Used 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 2.b. Date of Signature (mm/dd/yyyy)	[Page 10] Part 6. Interpreter’s Contact Information, Certification, and Signature Provide the following information concerning the interpreter. Interpreter’s Full Name 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country 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 [Fillable Field], which is the same language provided in Part 5., Item Number 1.b.; 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 Number 1.b.; 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 Number 1.b. 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.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy)
Page 10, Part 6. Signature of Person Preparing This Application, If Other Than the Applicant	Part 6. Signature of Person Preparing This Application, If Other Than the Applicant Provide the following information concerning the preparer: 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. Zip Code 3.f. Postal Code 3.g. Province 3.h. Country Preparer's Contact Information 4. Daytime Phone Number (if any) Extension 5. E-Mail Address (If any) 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. 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 6.b. Date of Signature (mm/dd/yyyy)	[Page11] Part 7. Contact Information, Statement, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant Provide the following information concerning the preparer. Preparer’s Full Name 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Preparer’s Contact Information 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number (if any) 6. Preparer’s Email Address (if any) 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 7.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.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)
Page 10, Part 8. Signature for Placement On Employment Authorization Document	[Page 10] Part 8. Signature for Placement On Employment Authorization Document Provide your signature below. This signature will be scanned and duplicated for placement on your Employment Authorization Document. When signing, make sure that no part of your signature goes outside the lines of the box. Signature	[Page 11] [No change]
NEW		[Page 12] Part 9. 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.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable Field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable Field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable Field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable Field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable Field]

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