Form I-485 Supplement A I-485 Supplement A Supplement A to Form I-485, Adjustment of Status Under S

Supplement A to Form I-485,
Adjustment of Status Under Section 245(i)
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-485

OMB No. 1615-0023
Expires 12/31/2018

NOTE: Use Supplement A to Form I-485, Adjustment of Status 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.

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Part 1. Information About You

Part 2. Eligibility

Your Current Legal Name

Basis of INA Section 245(i) Eligibility

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

You claim eligibility to adjust status under INA section 245(i)
because (Select only one box):
1.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.

1.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.

1.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.

1.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.

1.e.

You are currently the spouse applying to accompany
or follow-to-join your spouse OR the child
(unmarried and under 21 years of age) applying to
accompany or follow-to-join your parent described in
Item Numbers 1.a. - 1.d.

1.c. Middle Name

U.S. Mailing Address

2.a. In Care Of Name (if any)
2.b. Street Number
and Name
2.c.

Apt.

Ste.

Flr.

2.d. City or Town
2.e. State

2.f.

ZIP Code

Other Information
3.

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

4.

USCIS Online Account Number (if any)
►

5.

Date of Birth (mm/dd/yyyy)

6.

Country of Birth

7.

Country of Citizenship or Nationality

Form I-485 Supplement A 06/26/17 N

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).
2.

Receipt Number of Petition (if any)

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Part 2. Eligibility (continued)

1.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.

1.j.

You have ever violated the terms of your
nonimmigrant status.

Information on Principal Beneficiary of Petition or Application
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
4.

Principal Applicant's A-Number (if any)

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► A-

Immigrant Category
5.

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

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 Numbers 1.a. - 1.g.

NOTE: Read the Penalties section of the Supplement A
Instructions before completing this part. You must file
Supplement A while in the United States.

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.

Part 3. Bars to Adjustment

1.a.

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):

I can read and understand English, and I have read
and understand every question and instruction on this
supplement and my answer to every question.

1.b.

The interpreter named in Part 5. read to me every
question and instruction on this supplement and my
answer to every question in

1.a.

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

1.b.

You last entered the United States as a nonimmigrant
crewman.

1.c.

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

1.d.

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

1.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.

1.f.

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

1.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.

1.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).

Form I-485 Supplement A 06/26/17 N

a language in which I am fluent, and I understood
everything.

2.

,

At my request, the preparer named in Part 6.,
prepared this supplement 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)

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

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

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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 law.
I certify, under penalty of perjury, that all of the information in
my supplement 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
supplement and that all of this information is complete, true,
and correct.

Applicant's Signature

3.f.

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

6.a. Applicant's Signature (sign in ink)

Interpreter's Certification

6.b. 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.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.

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 supplement and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
supplement, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature (sign in ink)

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

Interpreter's Business or Organization Name (if any)

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Part 6. Contact Information, Declaration, 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.a. Preparer's Family Name (Last Name)

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.

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 supplement.
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, with this
supplement.

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1.b. Preparer's Given Name (First Name)
2.

Preparer's Statement

Preparer's Business or Organization Name (if any)

Preparer's Certification

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

Apt.

Ste.

Flr.

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

Province

3.e. ZIP Code

3.g. Postal Code
3.h. Country

By my signature, I certify, under penalty of perjury, that I
prepared this supplement at the request of the applicant. The
applicant then reviewed this completed supplement and
informed me that he or she understands all of the information
contained in, and submitted with, his or her supplement,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this supplement 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 (sign in ink)

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

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Form I-485 Supplement A 06/26/17 N

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