Form Supplement A Supplement A Form I-485, Supplement A

OMB No. 1615-0023; Expires 10/31/2017

Supplement A to Form I-485,
Adjustment of Status Under Section 245(i)

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

NOTE: Use this form only if you are applying to adjust status to that of a lawful permanent resident under section 245(i) of
the Immigration and Nationality Act (INA).

Part A.

Information About You

Last Name

For USCIS Use Only

First Name

Action Block

Middle Name

Address: In Care Of
Street Number and Name

Apt. Number
State

City

Zip Code

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Alien Registration Number (A-No.) if any

Date of Birth (mm/dd/yyyy)

Country of Birth

Country of Citizenship/Nationality

Telephone Number

Email Address, if any

Part B.

Eligibility (Select the correct response)

1. I am filing Supplement A to Form I-485 because:
a.
I am the beneficiary of a visa petition filed on or before January 14, 1998.
I am the beneficiary of a visa petition filed on or after January 15, 1998, and on or before April 30, 2001.
b.
I am the beneficiary of an application for a labor certification filed on or before January 14, 1998.
c.
d.
I am the beneficiary of an application for a labor certification filed on or after January 15, 1998, and on or before April 30,
2001.
If you checked box b. or d. in Question 1., you must submit evidence demonstrating that you were physically present in the
United States on December 21, 2000.
2. And I fall into one or more of these categories: (Select all that apply to you)
a.
I entered the United States as an alien crewman;
b.

I have accepted employment without authorization;

c.

I am in unlawful immigration status because I entered the United States without inspection or I remained in the United
States past the expiration of the period of my lawful admission;

d.

I have failed (except through no fault of my own or for technical reasons) to maintain, continuously, lawful status;

e.
f.
g.

I was admitted to the United States in transit without a visa;
I was admitted as a nonimmigrant visitor without a visa;
I was admitted to the United States as a nonimmigrant in the S classification; or
I am seeking employment-based adjustment of status and am not in lawful nonimmigrant status.

h.

Part C.

Additional Eligibility Information

1. Are you applying to adjust status based on any of the below reasons?
a. You were granted asylum in the United States;
b. You have continuously resided in the United States since January 1, 1972;
c. You entered as a K-1 fiancé(e) of a U.S. citizen;
d. You have an approved Form I-360, Petition for Amerasian, Widow(er), Battered or Abused Spouse or Child, or Special
Immigrant, and are applying for adjustment as a special immigrant juvenile court dependent, a special immigrant who has
served in the U.S. armed forces, or a battered or abused spouse or child;
Form I-485 Supplement A (Rev. 10/05/15)Y

Part C.

Additional Eligibility Information (Continued)

e.

You are a native or citizen of Cuba, or the spouse or child of such alien, who was not lawfully inspected or admitted to the
United States;

f.

You are a special immigrant retired international organization employee or family member;
You are a special immigrant physician;

g.
h.

You are a public interest parolee, who was denied refugee status, and are from the former Soviet Union, Vietnam, Laos or
Cambodia (a "Lautenberg Parolee" under Public Law 101-167); or

i.

You are eligible under the Immigration Nursing Relief Act.
No. I am not applying for adjustment of status for any of these reasons. (Go to next question)
Yes. I am applying for adjustment of status for any one of these reasons. (If you answered "Yes," do not file this form.)

2. Do any of the following conditions describe you?

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a. You are already a lawful permanent resident of the United States.

b. You have continuously maintained lawful immigration status in the United States since November 5, 1986.

c. You are applying to adjust status as the spouse or unmarried minor child of a U.S. citizen or the parent of a U.S. citizen
child at least 21 years of age, and you were inspected and lawfully admitted to the United States.
No. None of these conditions describe me. (Go to Part D. Signature)
Yes. If you answered "Yes," do not file this form.

Part D. Signature Read the information on penalties in the instructions before completing this section.

I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted
with it is all true and correct. I authorize the release of any information from my records that the U.S. Citizenship and Immigration
Services needs to determine eligibility for the benefit being sought.
Signature

Part E.

Date

Print Name

Signature of Person Preparing Form, If Other Than Above

Read the information on penalties in the instructions before completing this section.

I certify, under penalty of perjury under the laws of the United States of America, that I prepared this form at the request of the above
person and that to the best of my knowledge the contents of this application are all true and correct.
Signature

Firm Name and Address

Date

Print Name

Daytime Telephone Number (Area Code and Number)

Email Address, if any

Form I-485 Supplement A (Rev. 10/05/15)Y Page 2