Form I-824 Application for Action on an Approved Application

Application for Action on an Approved Application or Petition
Department of Homeland Security
U.S. Citizenship and Immigration Services
Returned
Date

USCIS
Form I-824
OMB No. 1615-0044
Expires 09/30/2015

Fee Stamp

Action Block

Date

DRAFT
Not for
Production
09/09/2015

Resubmitted
Date

For
USCIS
Use
Only

Date

Relocated
Received

Sent

Remarks

Priority Date:

Date the Previously Approved Visa Petition Was
Filed (Form I-130, I-140 or I-360):
Date the Previous Visa Petition Was Approved
(Form I-130, I-140 or I-360):

Country of Chargeability:
Classification Code:

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)

► START HERE - Type or print in black ink.

Part 1. Information About You (Person filing this
Application)

9.

Country of Citizenship or Nationality

1.

10.

IRS Tax Number (if any)

11.

U.S. Social Security Number (if any)
►

12.

USCIS ELIS Account Number (if any)
►

I am the (select only one):

Applicant

Petitioner

on the previously approved application or petition.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
3.

Company or Organization Name (if any)

4.

Current/Recent Immigration Status

Mailing Address
13.a. In Care Of Name

NOTE: If you are a U.S. citizen, type or print “N/A”

13.b. Street Number
and Name

for Item Number 4.

13.c.

5.

Certificate of Naturalization or Citizenship Number
(if any)

Apt.

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

7.

Date of Birth (mm/dd/yyyy)

8.

Country of Birth

Form I-824 02/22/13 N

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13.d. City or Town
13.e. State

6.

Ste.

13.f. ZIP Code

13.g. Province
13.h. Postal Code
13.i. Country

Page 1 of 7

Part 1. Information About You (Person filing this
Application) (continued)
Physical Address
14.a. Street Number
and Name
Apt.

14.b.

14.c. City or Town
14.d. State
14.f. Province
14.g. Postal Code
14.h. Country

Part 3. Other Information
Provide the following information about the principal
beneficiary of the previous application or petition, if other
than you.
1.a. Form Number of Previously Approved Application or
Petition

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Flr.

1.b. Receipt Number (On Form I-797, Notice of Action)

14.e. ZIP Code

Part 2. Reason for Request

I am requesting (select only one):
1.a.

A duplicate approval notice.

1.b.

U.S. Citizenship and Immigration Services (USCIS)
to notify a new U.S. Consulate, different from the
one that I originally requested, through the U.S.
Department of State's National Visa Center (NVC) or
Kentucky Consular Center. USCIS will notify the
U.S. Consulate about the approval of a nonimmigrant
visa petition or about a new Port-of-Entry (the Portof-Entry is different from what I originally requested)
about the approval of a waiver application. Please
notify the U.S. Consulate or Port-of-Entry at:

1.c. Filing Date of Application or Petition (mm/dd/yyyy)

1.d. Approval Date (mm/dd/yyyy)

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c.

Middle Name

2.d. Date of Birth (mm/dd/yyyy)
2.e. Country of Birth

2.f.

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

2.g. Daytime Telephone Number

Mailing Address
3.a. In Care Of Name

1.c.

USCIS to notify a U.S. Consulate through the NVC
about my adjustment of status to permanent resident
in the United States. Please notify the U.S. Consulate
at:

3.b. Street Number
and Name
3.c.

Apt.

so that my spouse and/or children may accompany or
follow-to-join me.

3.d. City or Town

1.d.

USCIS to send my approved immigrant visa petition
to the NVC.

3.e

1.e.

USCIS to notify the U.S. Department of State that I
have become a U.S. citizen through naturalization.

3.g. Province

3.f.

Flr.

ZIP Code

3.h. Postal Code
3.i.

Form I-824 02/22/13 N

State

Ste.

Country

Page 2 of 7

Part 3. Other Information (continued)
Physical Address

12.c. Middle Name

4.a. Street Number
and Name
Apt.

4.b.

4.f.

4.g. Postal Code
4.h. Country

Dependents

Date of Birth (mm/dd/yyyy)

14.

Country of Birth

15.

Country of Citizenship or Nationality

16.

Relationship to Principal Applicant

17.

Dependent's Email Address (if any)

18.

Dependent's Daytime Telephone Number

19.

Family Name
(Last Name)
Given Name
(First Name)

Flr.

4.e. ZIP Code

Province

13.

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4.c. City or Town
4.d. State

12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)

If you selected Part 2., Item Number 1.c., provide the

following information about the dependents for whom
you are requesting follow-to-join benefits. If you need
additional space for your dependents, use the space
provided in Part 7. Additional Information, and include
all the information collected in Item Numbers 5.a. - 11.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
6.

Date of Birth (mm/dd/yyyy)

7.

Country of Birth

8.

Country of Citizenship or Nationality

9.

Relationship to Principal Applicant

10.

Dependent's Email Address (if any)

11.

Dependent's Daytime Telephone Number

Form I-824 02/22/13 N

19.
19.

Middle Name

20.

Date of Birth (mm/dd/yyyy)

21.

Country of Birth

22.

Country of Citizenship or Nationality

23.

Relationship to Principal Applicant

24.

Dependent's Email Address (if any)

25.

Dependent's Daytime Telephone Number

Page 3 of 7

Part 3. Other Information (continued)

Applicant's Statement

26.a. Family Name
(Last Name)
26.b. Given Name
(First Name)

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
1.a.

26.c. Middle Name

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27.

Date of Birth (mm/dd/yyyy)

28.

Country of Birth

29.

Country of Citizenship or Nationality

30.

Relationship to Principal Applicant

31.

Dependent's Email Address (if any)

1.b.

The interpreter named in Part 5. has also 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.

2.

32.

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 requested the services of and consented to
,

who
is
is not an attorney or accredited
representative, preparing this application for me.

Dependent's Daytime Telephone Number

Applicant's Contact Information

Foreign Address of Dependents
33.a. In Care Of Name

33.b. Street Number
and Name
33.c.

Apt.

Ste.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Flr.

33.d. City or Town
33.e. Province
33.f. Postal Code
33.g. Country

Contact Information of Dependents
34.

3.

Foreign Telephone Number

Part 4. Applicant's Statement, Contact
Information, Certification, and Signature

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 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 and any document submitted with my application
were provided by me and are complete, true, and correct.

NOTE: Read the information on penalties in the Penalties
section of the Form I-824 Instructions before completing this
part.

Form I-824 02/22/13 N

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

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

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09/09/2015

6.a. Applicant's Signature

Interpreter's Certification

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.

Part 5. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

I certify that:

I am fluent in English and
, which
is the same language provided in Part 4., 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 4., Item Number 1.b.; and
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.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

Interpreter's Signature

6.a. Interpreter's Signature

1.b. Interpreter's Given Name (First Name)

6.b. Date of Signature (mm/dd/yyyy)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Part 6. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Application, If Other Than the
Applicant

Provide the following information about the preparer.
Ste.

Flr.

Preparer's Full Name
3.c. City or Town
1.a. Preparer's Family Name (Last Name)
3.d. State
3.f.

Province

3.g. Postal Code

3.e. ZIP Code
1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

3.h. Country

Form I-824 02/22/13 N

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Part 6. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Application, If Other Than the
Applicant (continued)

3.b.

Apt.

Ste.

3.c. City or Town
3.d. State
3.f.

Province

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.

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Preparer's Mailing Address
3.a. Street Number
and Name

Preparer's Certification

Flr.

Preparer's Signature

3.e. ZIP Code

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

3.g. Postal Code
3.h. Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

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 Entry of Appearance
as Attorney or Accredited Representative or G-28I,
Notice of Entry of Appearance as Attorney In Matters
Outside of the Geographical Confines of the United
States, with this application.

Form I-824 02/22/13 N

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5.a. Page Number

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. 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.

Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.d.

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A-Number (if any)

5.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

A- ►

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

4.b. Part Number

4.c. Item Number

6.d.

4.d.

Form I-824 02/22/13 N

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