Current Page Number and
Section
|
Current Text
|
Proposed
Text
|
Page 1, For USCIS Use
Only
|
[Page
1]
For
USCIS Use Only
Date
Fee
Stamp
Action
Block
Received
Completed
Retd/Trans
out
Trans
in
|
[Page
1]
For
USCIS Use Only
Date
Fee
Stamp
Action
Block
Received
Completed
Retd/Trans
out
Trans
in
|
Page 1, To be completed
by an attorney or accredited representative (if any).
|
[Page
1]
To
be completed by an attorney or accredited representative (if any).
Select
this box if Form G-28 is attached.
Attorney
State Bar Number (if applicable)
Attorney or Accredited
Representative USCIS Online Account Number (if any)
|
[Page
1]
To
be completed by an Attorney
or Accredited
Representative.
Select
this box if Form G-28 is attached.
Attorney
State Bar Number
Attorney or Accredited
Representative USCIS Online Account Number
|
Page 1-3, Part 1.
Information About You
|
[Page
1]
START
HERE- Type or print in black ink.
Part
1. Information About You
I
am applying for permission to return to the United States under
the authority contained in former section 212(c) of the
Immigration and Nationality Act (INA).
1.
Your Full Name (do
not provide
a nickname)
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
2.
Other Names Used
List
all other names you have ever used, including aliases, maiden
name, and nicknames. If you need extra space to complete this
section, use the space provided in Part
12. Additional Information.
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
[Page
2]
8.
Mailing
Address
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
9.
Physical
Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Page
1]
3.
Date of Birth (mm/dd/yyyy)
4.
Alien Registration Number (A-Number) (if any)
5.
USCIS Online Account Number (if any)
7.
Country of Citizenship or Nationality
6.
Place of Birth
City/Town/Village
of Birth
State/Province
of Birth
Country
of Birth
[Page
2]
10.
Information
About When and How You Became a Lawful Permanent Resident (LPR)
A.
Date
When You Obtained Your LPR Status (mm/dd/yyyy)
B.
You
Obtained Your LPR Status Through (select only
one)
Admission
With an Immigrant Visa at a Port-of-Entry
Port-of-Entry,
If Known
Means
of Transportation
Adjustment
of Status While in the United States
USCIS
Office
11.
Passport
Number Used at Last Entry
12.
Travel
Document Number Used at Last Entry
13.
Country
of Issuance for Passport or Travel Document
14.
Expiration
Date of This Passport or Travel Document
(mm/dd/yyyy)
[Page
3]
15.
Information About Your Departures From and Returns To the United
States
Since
being admitted as an LPR, you have departed from and returned to
the United States as follows:
Departed
From The United States
[Table with three columns/three rows]
Place
or Port-of-Departure
Date
of Departure (mm/dd/yyyy)
Means
of Transportation
Returned
To The United States
[Table with three columns/three rows]
Place
or Port-of-Entry
Date
of Entry (mm/dd/yyyy)
Means
of Transportation
Purpose
of Trips
[Fillable
field]
|
[Page
1]
START
HERE- Type or print in black ink. Answer
all questions fully and accurately. If a question does not
apply to you (for example, if you have never been married and the
question asks, “Provide the name of your current spouse”),
type or print “N/A” unless otherwise directed.
If your answer to a question which requires a numeric response is
zero or none (for example, “How many children do you have?”
or “How many times have you departed the United States?”),
type or print “None” unless otherwise directed.
Part
1. Information About You
The
individual applying
for relief
under
former
Immigration and Nationality Act (INA) section
212(c) completes
this section.
1. Your Full Legal
Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
2. Other Names Used
Provide any
other names you have used at any time
since birth, including aliases, maiden names,
and nicknames. If you need extra space to complete this
section, use the space provided in Part 12. Additional
Information.
Family Name (Last Name)
[x2]
Given Name (First Name)[x2]
Middle Name
[x2]
3.
Current Mailing Address
In Care Of Name
Street Number and Name
Apt./Ste./Flr. Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
4.
Is your current mailing address the same as your physical address?
Yes
No
NOTE: If
you answered "No" to Item
Number 4., provide your physical
address below.
[Page 2]
5. Current
Physical Address
(if different from the address above)
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
Other
Information
6.
Date
of Birth (mm/dd/yyyy)
7. Alien
Registration Number (A-Number)
8.
USCIS Online Account Number
9. Your
Country of Citizenship or
Nationality
List the
country where you are currently a citizen or national. If you
need extra space to complete this item, use the space provided in
Part 12. Additional Information.
10. Place
of Birth
List the
city/town/village, state/ province, and country where you were
born.
City/Town/Village
of Birth
State/Province
of Birth
Country of
Birth
11.
Information
About Your
Lawful Permanent
Resident (LPR)
Status
A.
Date
You Obtained
Your LPR Status (mm/dd/yyyy)
B.
How
You
Obtained Your LPR Status
(select
only
one box)
Admission
with an Immigrant Visa at a Port
of Entry
(Complete
Item Number 12.)
Adjustment
of Status Granted by USCIS While in the United States (Complete
Item Number 13.)
Adjustment
of Status Granted by Immigration Judge or Board of Immigration
Appeals While Inside the United States (Complete
Item Number 14.)
12.
If
you selected “Admission with an Immigrant Visa at a Port of
Entry,” provide the information requested below.
Port-of-Entry
City
or Town
Port-of-Entry
State
Means
of Transportation
13.
If
you selected “Adjustment of Status Granted by USCIS While in
the United States,” provide the USCIS
Office
location
that granted your adjustment of status application below.
USCIS
Office Location
14.
If you selected “Adjustment
of Status by Immigration Judge or Board of Immigration Appeals
While inside the United States” provide the date your status
was granted and the location of the Immigration Judge below.
Date
Adjustment of Status was Granted
Location
of Immigration Judge
Information
About Your Last Arrival in the United States
15.
Passport or Travel Document
Number
16.
Country That Issued Your
Passport or Travel Document
17.
Expiration Date for Your
Passport or Travel Document (mm/dd/yyyy)
18. Date
of Your Last Arrival into United States, On or About (mm/dd/yyyy)
[Page
3]
Information
About
Your Travels
From and To the
United States
Provide
the information requested below about your travels from
and
to
the United States
since you were admitted as, or adjusted your status to, an LPR.
If you need extra space to complete this section, use the space
provided in Part
12. Additional Information.
19.
Trip 1
City
of Departure
State
of Departure
Date
of Departure (mm/dd/yyyy)
Means
of Transportation for
Departure
City
of Arrival
State
of Arrival
Date
of Arrival
(mm/dd/yyyy)
Means
of Transportation for
Arrival
Purpose
of Trip
Is
this information approximate?
Yes
No
20.
Trip 2
City
of Departure
State
of Departure
Date
of Departure (mm/dd/yyyy)
Means
of Transportation for
Departure
City
of Arrival
State
of Arrival
Date
of Arrival
(mm/dd/yyyy)
Means
of Transportation for
Arrival
Purpose
of Trip
Is
this information approximate?
Yes
No
21.
Trip 3
City
of Departure
State
of Departure
Date
of Departure (mm/dd/yyyy)
Means
of Transportation for
Departure
City
of Arrival
State
of Arrival
Date
of Arrival
(mm/dd/yyyy)
Means
of Transportation for
Arrival
Purpose
of Trip
Is
this information approximate?
Yes
No
|
Page 4, Part 2.
Biographic Information
|
[Page
4]
Part
2. Biographic Information
1.
Ethnicity
(Select only
one
box)
Hispanic
or Latino
Not
Hispanic or Latino
2.
Race
(Select all
applicable
boxes)
White
Asian
Black
or African American
American
Indian or Alaska Native
Native
Hawaiian or Other Pacific Islander
3.
Height
Feet
Inches
4.
Weight
Pounds
5.
Eye
Color (Select
only
one
box)
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Pink
Unknown/Other
6.
Hair
Color (Select
only
one
box)
Bald
(No hair)
Black
Blond
Brown
Gray
Red
Sandy
White
Unknown/Other
|
[Page
4]
Part
2. Biographic Information
1.
Ethnicity
(Select only
one
box)
Hispanic
or Latino
Not
Hispanic or Latino
2.
Race
(Select all
applicable
boxes)
American
Indian or Alaska Native
Asian
Black
or African American
Native
Hawaiian or Other Pacific Islander
White
3.
Height
Feet
Inches
4.
Weight
Pounds
5.
Eye
Color (Select
only
one
box)
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Pink
Unknown/Other
6.
Hair
Color
(Select only
one
box)
Bald
(No hair)
Black
Blond
Brown
Gray
Red
Sandy
White
Unknown/Other
|
Page 4-5, Part 3.
Information About Your Criminal Convictions
|
[Page 4]
Part
3. Information About Your Criminal Convictions
The
information you provide below relates to the criminal convictions
for which you are seeking relief under former section 212(c) of
the Immigration and Nationality Act.
1.
Criminal Conviction 1
A. Date
(mm/dd/yyyy)
B. Name
of Court
C.
Location of Court
Town or City
State
D. Court
Case Number
E.
Conviction Entered
After Trial
Based on
Guilty or No Contest Plea
If based on
guilty or no contest plea, give the date of the guilty or no
contest plea (mm/dd/yyyy)
F.
Specific Offense as Stated in the Conviction Judgment (If
there is more than one offense, provide the name of each specific
offense.)
[Fillable
field]
G.
Citation to Federal, State, or Local Law, as Stated in the
Conviction Judgment (If there is more than one citation, provide
each separate citation.)
[Fillable
field]
H.
Sentence, Probation, or Other Punishment Imposed
[Page 5]
2.
Criminal Conviction 2
A. Date
(mm/dd/yyyy)
B. Name
of Court
C.
Location of Court
Town or City
State
D. Court
Case Number
E.
Conviction Entered
After Trial
Based on
Guilty or No Contest Plea
If based on
guilty or no contest plea, give the date of the guilty or no
contest plea (mm/dd/yyyy)
F.
Specific Offense as Stated in the Conviction Judgment (If
there is more than one offense, provide the name of each specific
offense.)
G.
Citation to Federal, State, or Local Law, as Stated in the
Conviction Judgment (If there is more than one citation, provide
each separate citation.)
H.
Sentence, Probation, or Other Punishment Imposed
3.
Criminal Conviction 3
A. Date
(mm/dd/yyyy)
B. Name
of Court
C.
Location of Court
Town or City
State
D. Court
Case Number
E.
Conviction Entered
After Trial
Based on
Guilty or No Contest Plea
If based on
guilty or no contest plea, give the date of the guilty or no
contest plea (mm/dd/yyyy)
F.
Specific Offense as Stated in the Conviction Judgment (If
there is more than one offense, provide the name of each specific
offense.)
G.
Citation to Federal, State, or Local Law, as Stated in the
Conviction Judgment (If there is more than one citation, provide
each separate citation.)
H.
Sentence, Probation, or Other Punishment Imposed
NOTE:
If you were convicted more than three times, include the
information for each additional conviction in Part 12.
Additional Information.
|
[Page 4]
Part
3. Information About Your Criminal Convictions
The
information requested
below
relates to your
criminal
convictions for which you are seeking relief under
former
INA
section
212(c).
1.
Conviction 1
A. Date
(mm/dd/yyyy)
B. Name
of Court
[Deleted]
C.
City or Town of Court
State of
Court
D.
Court Case Number
E.
Conviction Entered
After Trial
Based on
Guilty or No Contest Plea
If you
selected “Based on Guilty or No Contest Plea,”
provide the date
the plea was entered (mm/dd/yyyy).
F.
Specific Offense as Stated in the Judgment
of Conviction
[Fillable
field]
NOTE:
If the conviction is related to
more than one offense, provide the name of each specific
offense.
G.
Citation to Federal, State, or Local Law, as Stated in
the Judgment of Conviction
[Fillable
field]
NOTE:
If the conviction is related to
more than one citation, provide each separate citation.
H.
Sentence, Probation, or Other Punishment Imposed
Imprisonment
Served From (mm/dd/yyyy)
Imprisonment
Served To (mm/dd/yyyy)
2.
Conviction 2
A.
Date (mm/dd/yyyy)
B.
Name of Court
[Deleted]
C.
City or Town of Court
State of
Court
D.
Court Case Number
E.
Conviction Entered
After Trial
Based on
Guilty or No Contest Plea
If you
selected “Based on Guilty or No Contest Plea,”
provide the date
the plea was entered (mm/dd/yyyy).
[Page 5]
F.
Specific Offense as Stated in the
Judgment of Conviction
[Fillable
field]
NOTE:
If the conviction is related to
more than one offense, provide the name of each specific
offense.
G.
Citation to Federal, State, or Local Law, as Stated in
the Judgment of Conviction
[Fillable
field]
NOTE:
If the conviction is related to
more than one citation, provide each separate citation.
H.
Sentence, Probation, or Other Punishment Imposed
Imprisonment
Served From (mm/dd/yyyy)
Imprisonment
Served To (mm/dd/yyyy)
3.
Conviction 3
A.
Date (mm/dd/yyyy)
B.
Name of Court
[Deleted]
C.
City or Town of Court
State of
Court
D.
Court Case Number
E.
Conviction Entered
After Trial
Based on
Guilty or No Contest Plea
If you
selected “Based on Guilty or No Contest Plea,”
provide the date
the plea was entered (mm/dd/yyyy).
F.
Specific Offense as Stated in the Judgment
of Conviction
[Fillable
field]
NOTE:
If the conviction is related to
more than one offense, provide the name of each specific
offense.
G.
Citation to Federal, State, or Local Law, as Stated in
the Judgment of Conviction
[Fillable
field]
NOTE:
If the conviction is related to
more than one citation, provide each separate citation.
H.
Sentence, Probation, or Other Punishment Imposed
Imprisonment
Served From (mm/dd/yyyy)
Imprisonment
Served To (mm/dd/yyyy)
NOTE:
If you have more than three convictions
(including conviction after trial, guilty pleas, and no contest
pleas), use the space provided in Part 12. Additional
Information to provide the requested
information about each additional conviction.
|
Page 6-7, Part 4.
Information About Your Residence
|
[Page 6]
Part
4. Information About Your Residence
Provide
the following information about where you have lived during the
last seven years.
List
your most recent residence first and then every other residence
where you have lived during the last seven years. There should be
no gaps in time. If you need extra space to complete this
section, use the space provided in
Part 12. Additional Information.
1.
Physical
Address 1
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
of Residence
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
2.
Physical
Address 2
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
of Residence
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
3.
Physical
Address 3
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
of Residence
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
4.
Physical
Address 4
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
of Residence
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
[Page 7]
5.
Physical
Address 5
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
of Residence
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
|
[Page 5]
Part
4. Information About Your Residences
Provide
the following information about where you have lived during the
last seven years. List your most recent residence first and then
every
residence
where you have lived during the last seven years. You
should not have any gaps
in time. If you need extra space to complete this section, use
the space provided in
Part 12. Additional Information.
1.
Physical
Address 1
[Deleted]
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Deleted]
Resided
From
(mm/dd/yyyy)
Resided
To
(mm/dd/yyyy)
[Page 6]
2.
Physical Address 2
[Deleted]
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Deleted]
Resided
From
(mm/dd/yyyy)
Resided
To
(mm/dd/yyyy)
3.
Physical Address 3
[Deleted]
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Deleted]
Resided
From
(mm/dd/yyyy)
Resided
To
(mm/dd/yyyy)
4.
Physical Address 4
[Deleted]
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Deleted]
Resided
From
(mm/dd/yyyy)
Resided
To
(mm/dd/yyyy)
[Deleted]
|
Page 7-8, Part 5.
Information About Your Employment
|
[Page 7]
Part
5. Information About Your Employment
Provide
the following information about your employment.
List
where you have worked full-time or part-time during the last seven
years. If you need extra space to complete this section, use the
space provided in
Part 12. Additional Information.
1.
Employer
1
Name
of Employer
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Your
Occupation
2.
Employer
2
Name
of Employer
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Your
Occupation
[Page
8]
3.
Employer
3
Name
of Employer
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Date
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Your
Occupation
|
[Page 6]
Part
5. Information About Your Employment
Provide
the following information about
where you
have worked full-time or part-time during the last seven years.
List
your most recent employer first and then list every other employer
where you worked at any time during the last seven years. If you
were unemployed, type or print “Unemployed” in the
“Name of Employer” field and provide applicable
information. If
you need extra space to complete this section, use the space
provided in
Part 12. Additional Information.
1.
Employer 1
Name
of Employer
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Deleted]
Employed
From
(mm/dd/yyyy)
Employed
To
(mm/dd/yyyy)
[Page
7]
Your
Occupation
2.
Employer 2
Name
of Employer
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Deleted]
Employed
From
(mm/dd/yyyy)
Employed
To
(mm/dd/yyyy)
Your
Occupation
3.
Employer 3
Name
of Employer
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Deleted]
Employed
From
(mm/dd/yyyy)
Employed
To
(mm/dd/yyyy)
Your
Occupation
4.
Employer 4
Name
of Employer
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Employed
From
(mm/dd/yyyy)
Employed
To (mm/dd/yyyy)
Your
Occupation
|
Page 8-11, Part 6.
Information About Your Family
|
[Page 8]
Part
6. Information About Your Family
Provide
the following information about your family (for example, spouse,
children, and parents). If you need extra space to complete this
section, use the space provided in
Part 12. Additional Information.
A.
Information About Your Spouse
Spouse's
Current Legal Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Spouse's
Country of Birth
Spouse's
Date of Birth (mm/dd/yyyy)
Spouse's
Country of Citizenship or Nationality
Spouse's
Physical Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Page 9]
B.
Information About Your Children
Provide
the following information about all of your children.
Child
1
Current
Legal Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Country
of Birth
Date
of Birth (mm/dd/yyyy)
Country
of Citizenship or Nationality
Current
Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Child
2
Current
Legal Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Country
of Birth
Date
of Birth (mm/dd/yyyy)
Country
of Citizenship or Nationality
Current
Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Page
10]
Child
3
Current
Legal Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Country
of Birth
Date
of Birth (mm/dd/yyyy)
Country
of Citizenship or Nationality
Current
Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Child
4
Current
Legal Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Country
of Birth
Date
of Birth (mm/dd/yyyy)
Country
of Citizenship or Nationality
Current
Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Page
11]
C.
Information About Your Parents
Parent 1
Parent
1’s Current Legal Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Sex
Male
Female
Parent 1’s
Date of Birth (mm/dd/yyyy)
Parent 1’s
Country of Birth
Parent 1’s
Country of Citizenship or Nationality
Parent
1’s Physical Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Parent 2
Parent
2’s Current Legal Name
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
Sex
Male
Female
Parent 2’s
Date of Birth (mm/dd/yyyy)
Parent 2’s
Country of Birth
Parent 2’s
Country of Citizenship or Nationality
Parent
2’s Physical Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
|
[Page 7]
Part
6. Information About Your Family
Provide
the following information about your
spouse,
all
children,
and your
parents.
If you need extra space to complete this section, use the space
provided in
Part 12. Additional Information.
[Deleted]
1.
Spouse's
Current Legal Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
Spouse’s
Other Information
2. A-Number
3.
USCIS Online Account Number
4. Spouse’s
Gender
Male
Female
5.
Date of
Birth (mm/dd/yyyy)
[Page
8]
6. Country
of Birth
7. Country
of Citizenship or Nationality
8.
Spouse's Physical Address
[] Same as
applicant’s
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
[Deleted]
9.
Current
Legal Name of
Child
1
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other
Information for Child 1
10.
A-Number
11.
USCIS Online Account Number
12. Child’s
Gender
Male
Female
13.
Date
of Birth (mm/dd/yyyy)
14. Country
of Birth
15. Country
of Citizenship or Nationality
16.
Physical Address of
Child 1
[] Same as
applicant’s
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
17.
Current
Legal Name of
Child
2
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other
Information for Child 2
18.
A-Number
19.
USCIS Online Account Number
20. Child’s
Gender
Male
Female
21.
Date
of Birth (mm/dd/yyyy)
22. Country
of Birth
23. Country
of Citizenship or Nationality
24.
Physical Address of Child 2
[] Same as
applicant’s
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
[Page
9]
25.
Current
Legal Name of
Child
3
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other
Information for Child 3
26.
A-Number
27.
USCIS Online Account Number
28. Child’s
Gender
Male
Female
29.
Date
of Birth (mm/dd/yyyy)
30. Country
of Birth
31. Country
of Citizenship or Nationality
32.
Physical Address of Child 3
[] Same as
applicant’s
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
33.
Current
Legal Name of
Child
4
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other
Information for Child 4
34.
A-Number
35.
USCIS Online Account Number
36. Child’s
Gender
Male
Female
37.
Date
of Birth (mm/dd/yyyy)
38. Country
of Birth
39. Country
of Citizenship or Nationality
40.
Physical Address of Child 4
[] Same as
applicant’s
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
Information
About Your Parents
41.
Current Legal
Name of
Parent
1
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other
Information for Parent 1
42.
A-Number
43.
USCIS Online Account Number
44.
Gender
Male
Female
45.
Date
of
Birth (mm/dd/yyyy)
46. Country
of Birth
[Page 10]
47. Country
of Citizenship or Nationality
48.
Physical Address of Parent 1
[] Same as
applicant’s
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
49.
Current Legal
Name of
Parent
2
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other
Information for Parent 2
50.
A-Number
51.
USCIS Online Account Number
52.
Gender
Male
Female
53.
Date
of
Birth (mm/dd/yyyy)
54. Country
of Birth
55. Country
of Citizenship or Nationality
56.
Physical Address of Parent 2
[] Same as
applicant’s
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
|
Page 12, Part 7. Other
Grounds for Removal
|
[Page 12]
Part 7.
Other Grounds for Removal
If you need
extra space to complete your statement, use the space provided in
Part 12. Additional Information or attach a separate
letter.
If you
believe you may be subject to removal on any grounds besides the
criminal convictions listed in Part 3. Information About
Your Criminal Convictions, provide a full explanation of why
you may be subject to removal.
The other
grounds of removal may be any inadmissibility grounds in section
212(a) of the Immigration and Nationality Act or any deportability
grounds in section 237(a) of the Immigration and Nationality Act.
If you have a
criminal history besides the criminal convictions listed in Part
3. Information About Your Criminal Convictions, list
these incidents and provide a full explanation. If you have ever
been arrested or detained by any law enforcement officer for any
reason, and no charges were filed, include an original official
statement by the arresting or detaining agency or applicable court
order confirming that no charges were filed.
If you were
arrested or detained by any law enforcement officer for any reason
and charges were filed, or if charges were filed against you
without an arrest, submit an original or court-certified copy of
the complete arrest record and/or disposition for each incident
(for example, a dismissal order or an acquittal order).
[Fillable
field]
|
[Page 10]
Part 7.
Other Grounds for Removal
NOTE:
If you need extra space to complete this
section, use the space provided in Part 12. Additional
Information.
1.
Provide an explanation in the
space provided why you may be subject to removal on any
grounds besides the criminal convictions listed in Part 3.
Information About Your Criminal Convictions.
The other grounds of removal may include
any inadmissibility grounds in INA
section 212(a) or any deportability
grounds in INA section 237(a).
[Fillable
field]
[Page 11]
2.
In addition to the criminal
convictions listed in Part 3.,
list and provide a full explanation of any other time you
committed, or were accused of committing, a criminal offense
inside or outside of the United States, as well as any other time
you were arrested, cited, detained, charged, investigated,
received deferred adjudication of guilt, withholding of
adjudication of guilt, or pretrial diversion, or plead guilty to
or were convicted of a criminal offense inside or outside of the
United States.
NOTE:
If you were ever arrested,
detained, or investigated by any law
enforcement officer for any reason, and no charges were filed,
include an original official statement by the arresting or
detaining agency or applicable court order confirming that no
charges were filed. If you were ever
arrested, detained, or investigated
by any law enforcement officer for any reason and charges were
filed, or if charges were filed against you without an arrest,
submit an original or court-certified copy of the complete arrest
record and/or disposition for each incident (for example, a
dismissal order or an acquittal order).
[Fillable
field]
|
Page 12, Part 8.
Discretion
|
[Page 12]
Part 8.
Discretion
In the space
provided below, explain why you believe your application should be
approved as a matter of discretion, with the favorable factors
outweighing the unfavorable factors in your case. For more
information on discretion, see the application Instructions. If
you need extra space to complete your statement, use the space
provided in Part 12. Additional Information, or attach a
separate letter. Indicate in the space provided if you are
including a separate letter. If you submit a separate letter, you
must submit the letter at the same time as your Form I-191
application.
[Fillable
field]
|
[Page 11]
Part 8.
Discretion
1.
In the space provided below, explain why
U.S. Citizenship and Immigration Services (USCIS) or the
immigration judge should approve your Form I-191 as a
matter of discretion, with the favorable factors outweighing the
unfavorable factors in your case. For more information on
discretion, see the Form I-191 Instructions.
If you need extra space to complete your statement, use the space
provided in Part 12. Additional Information.
NOTE:
You may provide your explanation on a separate sheet
of paper. If you use a separate sheet, select the box below and
include that sheet with your Form I-191. You must submit
your explanation at the same time as
your Form I-191.
[Fillable
field]
2.
[] I provided my explanation on a separate sheet and included that
sheet with this Form I-191.
|
Page 13, Part 9.
Applicant’s Statement, Contact Information, Certification,
and Signature
|
[Page 13]
Part 9.
Applicant’s Statement, Contact Information, Certification,
and Signature
NOTE:
Read the Penalties section of the Form I-191 Instructions
before completing this part.
Applicant’s
Statement
NOTE:
Select the box for either Item A. or B. in Item
Number 1. If applicable, select the box for Item Number 2.
1.
Applicant's Statement Regarding the Interpreter
A. 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.
B. The
interpreter named in Part 10. read to me every question and
instruction on this application and my answer to every question,
in [Fillable field], a language in which I am fluent and I
understood everything.
2.
Applicant's Statement Regarding the Preparer
At my
request, the preparer named in Part 11., [Fillable field],
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’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 of my records
that USCIS may need to determine my eligibility for the
immigration benefit I seek.
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.
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 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.
I certify,
under penalty of perjury, that I provided or authorized all of the
information in my application, I 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.
Applicant's Signature
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 (or an immigration judge if you are in
deportation, exclusion, or removal proceedings) may deny your
application.
|
[Page 12]
Part
9. Applicant’s
Statement, Contact Information, Certification, and Signature
NOTE:
Read the Penalties
section of the Form I-191 Instructions before completing this
section.
Applicant’s
Statement
NOTE:
Select the box for either Item
Number A. or
B. in
Item
Number 1.
If
applicable, select the box for Item
Number 2.
1.
Applicant's Statement Regarding the Interpreter
A.
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.
B.
The interpreter named in Part
10.
read to me every
question and instruction on this application
and
my answer to every question in [Fillable Field], a language in
which I am fluent, and I understood everything.
2.
Applicant's Statement Regarding the Preparer
At
my request, the preparer named in Part
11.,
[Fillable field], 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
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 law.
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
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.
I
certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I 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.
Applicant’s Signature
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
or the immigration judge may deny
your application.
|
Page 14, Part 10.
Interpreter’s Contact Information, Certification, and
Signature
|
[Page 14]
Part 10.
Interpreter’s Contact Information, Certification, and
Signature
Provide the
following information about the interpreter.
Interpreter’s
Full Name
1.
Interpreter's Family Name (Last Name)
Interpreter's
Given Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
Interpreter’s
Mailing Address
3.
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
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)
Interpreter’s
Certification
I certify,
under penalty of perjury, that:
I am fluent
in English and [Fillable field], which is the same language
specified in Part 9., Item B., in Item Number 1.,
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.
Interpreter's Signature
Date of
Signature (mm/dd/yyyy)
|
[Page 13]
Part
10. Interpreter’s Contact Information,
Certification,
and Signature
If
you used an interpreter (as indicated in Part 9. Item
B.
in Item
Number 1.),
you must provide the
following information about the interpreter. The
interpreter must sign the Interpreter’s Certification below.
Interpreter’s
Full Name
1.
Interpreter’s Family Name (Last Name)
Interpreter’s
Given Name (First Name)
2.
Interpreter’s Business or Organization Name (if any)
Interpreter’s
Mailing Address
3.
Street Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
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)
Interpreter’s
Certification
I
certify, under penalty of perjury, that:
I
am fluent in English and [Fillable
Field],
which
is the same language specified in Part
9.,
Item
B., in
Item
Number 1.,
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.
Interpreter’s Signature
Date
of Signature (mm/dd/yyyy)
|
Page 15, Part 11.
Contact Information, Declaration, and Signature of the Person
Preparing This Application, if Other Than the Applicant
|
[Page 15]
Part 11.
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
1.
Preparer’s Family Name (Last Name)
Preparer’s
Given Name (First Name)
2.
Preparer’s Business or Organization Name (if any)
Preparer’s
Mailing Address
3.
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
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)
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.
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, you must
submit a completed Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this application.
Preparer’s
Certification
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.
Preparer’s Signature
Date of
Signature (mm/dd/yyyy)
|
[Page 13]
Part
11. 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
1.
Preparer’s Family Name (Last Name)
Preparer’s
Given Name (First Name)
2.
Preparer’s Business or Organization Name (if any)
Preparer’s
Mailing Address
3.
Street Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
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)
[Page
14]
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.
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, you may
need to submit
a completed Form G-28, Notice of Entry of Appearance as Attorney
or Accredited Representative, with this application.
Preparer’s
Certification
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.
Preparer’s Signature
Date of Signature (mm/dd/yyyy)
|
Page 16, Part 12.
Additional Information
|
[Page 16]
Part 12. 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.
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
2. A-Number (if any)
3. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
4. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
5. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
6. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
|
[Page 15]
Part
12. 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
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.
Family
Name (Last Name) [Auto-populated field]
Given
Name (First Name) [Auto-populated field]
Middle
Name [Auto-populated field]
2.
A-Number
[Auto-populated field]
3.A.
Page
Number
B.
Part
Number
C.
Item
Number
D.
[Fillable
field]
4.A.
Page
Number
B.
Part
Number
C.
Item
Number
D.
[Fillable
field]
5.A.
Page
Number
B.
Part
Number
C.
Item
Number
D.
[Fillable
field]
6.A.
Page
Number
B.
Part
Number
C.
Item
Number
D.
[Fillable
field]
7.A.
Page
Number
B.
Part
Number
C.
Item
Number
D.
[Fillable field]
NOTE TO ALL
APPLICANTS: Do not complete Part 13. USCIS will complete this
section.
|
Page 17, For USCIS Use
Only
|
[Page 17]
For USCIS Use Only
Decision
Application granted upon the
following terms and conditions:
[Fillable field]
Date of Action (mm/dd/yyyy)
|
[Page 16]
Part 13.
USCIS Decision (For
Official Use Only)
[Deleted]
1.
This application is:
Granted
Denied
2.
Terms and Conditions
[Fillable field]
3.
Date of Action (mm/dd/yyyy)
|