Pages 9-14,
Part 8. General
Eligibility and Inadmissibility Grounds
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62. Are
you likely to receive public assistance in the future in the
United States from any source, including the U.S. Government or
any state, county, city, or municipality (other than emergency
medical treatment)?
Yes
No
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Illegal Entries and Other
Immigration Violations
63.a. Have you EVER
failed or refused to attend or to remain in attendance at any
removal proceeding filed against you on or after April 1, 1997?
Yes/No
63.b. If your answer to Item
Number 63.a. is "Yes," do you believe you had
reasonable cause? Yes/No
63.c. If your answer to Item
Number 63.b. is "Yes," attach a written statement
explaining why you had reasonable cause.
64. Have you EVER
submitted fraudulent or counterfeit documentation to any U.S.
Government official to obtain or attempt to obtain any immigration
benefit, including a visa or entry into the United States?
Yes/No
65. Have you EVER lied
about, concealed, or misrepresented any information on an
application or petition to obtain a visa, other documentation
required for entry into the United States, admission to the United
States, or any other kind of immigration benefit?
Yes/No
66. Have you EVER
falsely claimed to be a U.S. citizen (in writing or any other
way)?
Yes/No
67. Have you EVER been
a stowaway on a vessel or aircraft arriving in the United States?
Yes/No
68. Have you EVER
knowingly encouraged, induced, assisted, abetted, or aided any
foreign national to enter or to try to enter the United States
illegally (alien smuggling)? Yes/No
69. Are you under a final
order of civil penalty for violating INA section 274C for use of
fraudulent documents? Yes/No
Removal, Unlawful Presence, or
Illegal Reentry After Previous Immigration Violations
70. Have you EVER been
excluded, deported, or removed from the United States or have you
ever departed the United States on your own after having been
ordered excluded, deported, or removed from the United States?
Yes/No
71. Have you EVER
entered the United States without being inspected and admitted or
paroled? Yes/No
Since April 1, 1997, have you been
unlawfully present in the United States:
72.a. For more than 180 days
but less than a year, and then departed the United States?
Yes/No
72.b. For one year or more
and then departed the United States? Yes/No
NOTE: You were unlawfully
present in the United States if you entered the United States
without being inspected and admitted or inspected and paroled, or
if you legally entered the United States but you stayed longer
than permitted.
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Since April 1, 1997, have you EVER
reentered or attempted to reenter the United States without
being inspected and admitted or paroled after:
73.a. Having been unlawfully
present in the United States for more than one year in the
aggregate? Yes/No
73.b. Having been deported,
excluded, or removed from the United States? Yes/No
Miscellaneous Conduct
74. Do you plan to practice
polygamy in the United States? Yes/No
75. Are you accompanying
another foreign national who requires your protection or
guardianship but who is inadmissible after being certified by a
medical officer as being helpless from sickness, physical or
mental disability, or infancy, as described in INA section 232(c)?
Yes/No
76. Have you EVER
assisted in detaining, retaining, or withholding custody of a U.S.
citizen child outside the United States from a U.S. citizen who
has been granted custody of the child? Yes/No
77. Have you EVER
voted in violation of any Federal, state, or local constitutional
provision, statute, ordinance, or regulation in the United States?
Yes/No
78. Have you EVER
renounced U.S. citizenship to avoid being taxed by the United
States? Yes/No
Have you EVER:
79.a. Applied for exemption
or discharge from training or service in the U.S. armed forces or
in the U.S. National Security Training Corps on the ground that
you are a foreign national?
Yes/No
79.b. Been relieved or
discharged from such training or service on the ground that you
are a foreign national? Yes/No
79.c. Been convicted of
desertion from the U.S. armed forces? Yes/No
80.a. Have you EVER
left or remained outside the United States to avoid or evade
training or service in the U.S. armed forces in time of war or a
period declared by the President to be a national emergency?
Yes/No
80.b. If your answer to Item
Number 80.a. is “Yes,” what was your
nationality or immigration status immediately before you left (for
example, U.S. citizen or national, lawful permanent resident,
nonimmigrant, parolee, present without admission or parole, or any
other status)?
[Fillable field]
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62. Are
you likely to receive public assistance in the future in the
United States from any source, including the U.S. Government or
any state, county, city, or municipality (other than emergency
medical treatment)?
Yes
No
I
am EXEMPT from filing Form I-864 because:
63.a.
I have earned or can receive credit for 40 qualifying quarters
(credits) of work in the United States (as defined by the Social
Security Act (SSA)). (Attach your SSA earnings statements. Do
not count any quarters during which you received a means-tested
public benefit).
63.b.
I am under 18 years of age, unmarried, immigrating as the child
of a U.S. citizen, am not likely to become a public charge and
will automatically become a U.S. citizen under INA section 320
upon my admission to the United States.
63.c.
I am applying under the widow or widower of a U.S. citizen (Form
I-360) immigrant category.
63.d.
I am applying under an alien worker (Form I-140) employment-based
preference immigrant category and both of the following apply:
(1)
I am not a relative of the Form I-140 petitioner; and
(2)
I do not have a relative with a significant ownership interest (at
least five percent) in the business that filed Form I-140.
63.e.
I am applying under the alien entrepreneur (Form I-526) immigrant
category.
63.f.
I am applying under the human trafficking victim (T nonimmigrant)
immigrant category (INA section 245(l)).
63.g.
I am applying under a category other than the human trafficking
victim (T nonimmigrant) category (INA section 245(l)), or as an
alien worker under the employment-based preference categories
where a relative filed Form I-140 for me or has a five percent or
more ownership interest in the business that filed Form I-140, and
I either have a pending application for T nonimmigrant status or I
am an individual who is in valid T nonimmigrant status.
NOTE:
If, when USCIS adjudicates your adjustment application, your Form
I-914 is no longer pending a decision or you are no longer in
valid T nonimmigrant status, you may have to submit a Form I-944
and Form I-864.
63.h.
I am applying under the victim of
qualifying criminal activity (U nonimmigrant) immigrant category
(INA section 245(m)).
63.i. I
am applying under a category other than the victim of qualifying
criminal activity (U nonimmigrant) category under INA section
245(m) or as an alien worker under the employment-based preference
categories where a relative filed Form I-140 for me or has a five
percent or more ownership interest in the business that filed Form
I-140, but I either have a pending petition for U nonimmigrant
status or I am an individual who is granted U nonimmigrant status.
NOTE:
If, at the time of the adjudication of the Form I-485, your Form
I-918 is no longer pending a decision or you are no longer in
valid U nonimmigrant status, you may be required to submit Form
I-944 and Form I-864.
63.j.
I am applying under the diplomat or high ranking official unable
to return home (Section 13 of the Act of September 11, 1957)
immigrant category.
63.k.
I am a law enforcement officer filing this Form I-485 for an S
nonimmigrant immigrant (or a qualifying family member).
63.l.
[ ] I am applying under the Diversity Visa program immigrant
category.
63.m.
[ ] I am applying under one of the following special immigrant
categories (select one):
[ ] Armed
Forces (also known as the Six and Six program)
[ ] Panama
Canal Zone
[ ] Certain
broadcasters
[ ] G-4 or
NATO-6 employees and their family members
[ ]
International employees of the U.S. Government abroad
[ ] Religious
workers
[ ] Certain
physicians
[ ] Employed
by or on behalf of the U.S. Government
63.n.
[ ] I am applying under the Amerasian Act (October 22, 1982)
63.o.
[ ] Applicant adjusting under the Amerasian Homecoming Act of
1987, Form I-360
63.p.
[ ]Applicant adjusting under the Liberian Refugee Immigrant
Fairness Act of 2019
Illegal Entries and Other
Immigration Violations
64.a.
Have you EVER failed or refused to attend or to remain
in attendance at any removal proceeding filed against you on or
after April 1, 1997? Yes/No
64.b. If
your answer to Item Number 64.a.
is "Yes," do you believe you had reasonable cause?
Yes/No
64.c.
If your answer to Item Number 64.b.
is "Yes," attach a written statement
explaining why you had reasonable cause.
65. Have
you EVER submitted fraudulent or counterfeit documentation
to any U.S. Government official to obtain or attempt to obtain any
immigration benefit, including a visa or entry into the United
States? Yes/No
66.
Have you EVER lied about, concealed, or misrepresented
any information on an application or petition to obtain a visa,
other documentation required for entry into the United States,
admission to the United States, or any other kind of immigration
benefit?
Yes/No
67.
Have you EVER falsely claimed to be a U.S. citizen (in
writing or any other way)?
Yes/No
68.
Have you EVER been a stowaway on a vessel or aircraft
arriving in the United States?
Yes/No
69.
Have you EVER knowingly encouraged, induced, assisted,
abetted, or aided any foreign national to enter or to try to enter
the United States illegally (alien smuggling)? Yes/No
70. Are
you under a final order of civil penalty for violating INA section
274C for use of fraudulent documents? Yes/No
Removal, Unlawful Presence, or
Illegal Reentry After Previous Immigration Violations
71.
Have you EVER been excluded, deported, or removed from
the United States or have you ever departed the United States on
your own after having been ordered excluded, deported, or removed
from the United States? Yes/No
72. Have
you EVER entered the United States without being inspected
and admitted or paroled? Yes/No
Since April 1, 1997, have you been
unlawfully present in the United States:
73.a.
For more than 180 days but less than a year, and then departed
the United States?
Yes/No
73.b. For
one year or more and then departed the United States? Yes/No
NOTE: You were unlawfully
present in the United States if you entered the United States
without being inspected and admitted or inspected and paroled, or
if you legally entered the United States but you stayed longer
than permitted.
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Since April 1, 1997, have you EVER
reentered or attempted to reenter the United States without
being inspected and admitted or paroled after:
74.a.
Having been unlawfully present in the United States for more
than one year in the aggregate? Yes/No
74.b.
Having been deported, excluded, or removed from the
United States? Yes/No
Miscellaneous Conduct
75. Do
you plan to practice polygamy in the United States? Yes/No
76. Are
you accompanying another foreign national who requires your
protection or guardianship but who is inadmissible after being
certified by a medical officer as being helpless from sickness,
physical or mental disability, or infancy, as described in INA
section 232(c)? Yes/No
77. Have
you EVER assisted in detaining, retaining, or withholding
custody of a U.S. citizen child outside the United States from a
U.S. citizen who has been granted custody of the child? Yes/No
78.
Have you EVER voted in violation of any Federal, state,
or local constitutional provision, statute, ordinance, or
regulation in the United States? Yes/No
79. Have
you EVER renounced U.S. citizenship to avoid being taxed by
the United States? Yes/No
Have you EVER:
80.a.
Applied for exemption or discharge from training or service in
the U.S. armed forces or in the U.S. National Security Training
Corps on the ground that you are a foreign national?
Yes/No
80.b.
Been relieved or discharged from such training or service on
the ground that you are a foreign national? Yes/No
80.c. Been
convicted of desertion from the U.S. armed forces? Yes/No
81.a. Have
you EVER left or remained outside the United States to
avoid or evade training or service in the U.S. armed forces in
time of war or a period declared by the President to be a national
emergency? Yes/No
81.b. If
your answer to Item Number 81.a.
is “Yes,” what was your nationality or immigration
status immediately before you left (for example, U.S. citizen or
national, lawful permanent resident, nonimmigrant, parolee,
present without admission or parole, or any other status)?
[Fillable field]
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