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 10/31/2020

DRAFT
Not for
Production
11/16/2020

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.

NOTE TO ALL APPLICANTS: If you leave any fields blank on this form or fail to submit required documents listed in the
Instructions, U.S. Citizenship and Immigration Services (USCIS) may reject or deny your application

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.c. Middle Name

U.S. Mailing Address
2.a. In Care Of Name

2.b. Street Number
and Name
2.c.

Apt.

Ste.

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.

Flr.

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

1.a.

2.f.

ZIP Code
(USPS ZIP Code Lookup)

Other Information
3.

Alien Registration Number (A-Number)
► A-

4.

USCIS Online Account Number
►

5.

Date of Birth (mm/dd/yyyy)

6.

Country of Birth

7.

Country of Citizenship or Nationality

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.

Form I-485 Supplement A 10/15/19

Receipt Number of Petition

Page 1 of 4

Part 2. Eligibility (continued)

1.i.

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.

DRAFT
Not for
Production
11/16/2020
1.j.

Principal Applicant's A-Number
► A-

Immigrant Category
5.

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 2.a. - 8.e.

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):

1.b.

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

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

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

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

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 10/15/19

You have ever violated the terms of your
nonimmigrant status.

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

Part 3. Bars to Adjustment

1.a.

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.

,

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)

Page 2 of 4

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

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

DRAFT
Not for
Production
11/16/2020
3.b.

Apt.

Ste.

Flr.

Applicant's 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.
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 I provided or authorized
all of the information in my supplement, that I 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.c. City or Town
3.d. State
3.f.

3.e. ZIP Code

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)

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)

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 Certification, and has
verified the accuracy of every answer.

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

1.b. Interpreter's Given Name (First Name)
7.b. Date of Signature (mm/dd/yyyy)
2.

Interpreter's Business or Organization Name (if any)

Form I-485 Supplement A 10/15/19

Page 3 of 4

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Supplement, if Other Than the Applicant

Preparer's Statement
7.a.

DRAFT
Not for
Production
11/16/2020

Provide the following information about the preparer.

7.b.

Preparer's Full Name

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

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

2.

Preparer's Business or Organization Name (if any)

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

Apt.

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

I am not an attorney or accredited representative but
have prepared this supplement on behalf of the
applicant and with the applicant's consent.

Ste.

Flr.

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.
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.

Preparer's Certification

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 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.

3.e. ZIP Code

Preparer's Signature

3.f.

Province

3.g. Postal Code
3.h. Country

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 10/15/19

Page 4 of 4