Page
1
|
Other
Information [sub-header]
6. Alien
Registration Number (A-number)
7. USCIS
Online Account Number (if any)
8. U.S.
Social Security Number (if any)
9. Date of
Birth (mm/dd/yyyy)
10. Gender
M/F
11. Country
of Birth
12. Country
of Citizenship
|
Part 1. Information About You [section header]
1.a. Family
Name (Last Name)
1.b. Given
Name (First Name)
1.c. Middle
Name
2. Has your
name changed since the issuance of your last Permanent
Resident Card (Form I-551)? [] Yes [] No
NOTE: If you
answered "Yes" to Item Number 2., attach evidence
of your legal name change with this application.
Mailing
Address [sub-header]
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
4. Is your
current mailing address the same as your U.S. physical address []
Yes [] No
U.S. Physical
Address
5.a. Street
Number and Name
5.b. Apt.
Ste. Flr.
5.c. City or
Town
5.d. State
5.e. ZIP Code
Other
Information [sub-header]
6. Alien
Registration Number (A-number)
7. USCIS
Online Account Number (if any)
8. U.S.
Social Security Number (if any)
9. Date of
Birth (mm/dd/yyyy)
10. Sex M/F
11. Country
of Birth
12. Country
of Citizenship
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Pages
1-2
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Part 3. Processing Information [section header]
1. Date
Departed in the United States (mm/dd/yyyy)
2. Date of
Intended Travel to the United States (mm/dd/yyyy)
3. Are you
NOW, or were you EVER, in exclusion, deportation,
removal, or rescission proceedings? [] Yes [] No
If you answered
"Yes" to Item Number 3., provide details in the
space provided in Part 7. Additional Information.
4. Since you
were granted permanent residence, have you EVER filed Form
I-407, Abandonment of Lawful Permanent Resident Status, or
otherwise been judged to have abandoned your status? [] Yes [] No
If you answered
"Yes" to Item Number 4., provide details in the
space provided in Part 7. Additional Information.
5.a. Have
you EVER been issued a Travel Document? [] Yes [] No
If
you
answered
"Yes"
to
Item
Number
5.a.,
answer
Item
Numbers
5.b.
and
5.c.
for
the
last
document
issued
to
you and
provide
additional
details
in
the
space
provided
in
Part 7.
Additional
Information.
5.b. Date
Issued (mm/dd/yyyy)
5.c.
Disposition (attached, lost, etc.):
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Page
2
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Applicant
Certification
[Sub-header]
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
of my
records that USCIS may need to
I further
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.
1)
I reviewed and provided or authorized all of the information in my
application;
2)
I understood all of the information contained in, and submitted
with, my application; and
3)
All of this information was complete, true, and correct at the
time of filing.
|
Part 4. Applicant’s
Statement, Contact
Information, Certification, and Signature [header]
NOTE:
Read the Penalties
section of the Form 1-131A
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.
[Check Box]
I can read and understand English, and I
have read and understand every question and instruction on this
application and
my answer to every question.
1.b.
[Check Box]
The interpreter named in Part
5.
read to
me every question and instruction on
this application
and my
answer to every question in
______________, a language in which I
am fluent and I understood
everything.
2.
[Check Box]
At my request, the preparer named in
Part 6.,
_____________________, prepared this
application
for me
based only upon information I provided or authorized.
Applicant’s
Contact Information
3.
Applicant’s
Daytime Telephone Number
4.
Applicant’s
Mobile Telephone Number (if any)
5.
Applicant’s
Email Address (if any)
Applicant
Certification
[Sub-header]
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 I
seek.
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 understand
that USCIS may require me to appear for an appointment to take my
biometrics (fingerprints, photograph, and/or signature) and, at
that time, if I am required to provide biometrics, I will be
required to sign an oath reaffirming that:
1) I
reviewed and understood all of the information contained in, and
submitted with, my application; and
2) All
of this information was complete, true, and correct at the time of
filing.
I certify,
under penalty of perjury, that all of the information in my
application and any document submitted with it were provided or
authorized by me, that I reviewed and understand all of the
information contained in, and submitted with, my application and
that all of this information is 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.
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Pages
2-3
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I am fluent in English
and _______________,
which is the same language
specified
in Part 4.,
Item Number 1.b.,
and I
have read
to this applicant in
the identified language every
question and instruction on this application
and his or
her answer
to every question.
The applicant
informed
me that he
or she understands every instruction,
question, and answer
on the
application,
including the Applicant’s
Certification,
and has
verified
the accuracy of every answer
|
Part 5. Contact Information, Certification, and Signature of
the Interpreter [header]
Provide
the following information about the interpreter.
Interpreter’s
Full Name [Sub-header]
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 [Sub-header]
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 [Sub-header]
4.
Interpreter’s Daytime Telephone Number
5.
Interpreter’s Mobile Telephone Number (if any)
6.
Interpreter’s E-mail Address
Interpreter
Certification [Sub-header]
I
certify, under penalty of perjury, that:
I am fluent in
English and _______________,
which is the same language
specified
in Part 4.,
Item Number 1.b.,
and I
have read
to this applicant in
the identified language every
question and instruction on this application
and his or
her answer
to every question.
The applicant
informed
me that he
or she understands every instruction,
question, and answer
on the
application,
including the Applicant’s
Certification,
and has
verified
the accuracy of every answer.
Interpreter’s
Signature
7.a.
Interpreter’s Signature
7.b.
Date of Signature (mm/dd/yyyy)
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Page
3
|
Preparer’s
Certification [Sub-header]
By
my signature, I certify,
under penalty of perjury, that I prepared this application
at the request of the applicant. The applicant
then reviewed this
completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant’s
Certification,
and that all of this information is complete, true, and correct.
I completed this application
based only on
information that the applicant
provided to me or
authorized me to obtain or use.
|
Part 6. Contact Information,
Declaration,
and Signature of the Person Preparing this Application,
if Other
Than the Applicant
Provide
the following information about the preparer.
Preparer’s
Full Name [Sub-header]
1.a.
Preparer’s Family Name
(Last Name)
1.b.
Preparer’s Given Name
(First Name)
2.
Preparer’s Business or
Organization
Preparer’s
Mailing Address [Sub-header]
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
[Sub-header]
4.
Preparer’s Daytime Telephone Number
5.
Preparer’s Mobile Telephone Number (if any)
6.
Preparer’s Email Address (if any)
7.a.
[Check Box]
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.
[Check Box]
I am an attorney or accredited representative and my
representation of the applicant in this case [Check
Box] extends [Check
Box] does not extend beyond the
preparation of this application.
NOTE:
If you are an attorney or accredited
representative, you may be obliged to
submit a completed Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, or
G-28I, Notice of Entry of Appearance as Attorney In Matters
Outside the Geographical Confines of the United States, with
this application.
Preparer’s
Certification [Sub-header]
By
my signature, I certify,
under penalty of perjury, that I prepared this application
at the request of the applicant. The applicant
then reviewed this
completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant’s
Certification,
and that all of this information is complete, true, and correct.
I completed this application
based only on
information that the applicant
provided to me or
authorized me to obtain or use.
Preparer’s
Signature
8.a.
Preparer’s Signature
8.b.
Date of Signature (mm/dd/yyyy)
|
|
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.
|
Part 7. 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. Type or print
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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