OMB22-FRM-OMBApproved-07232020-Word

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Dear Sir or Madam:
Case Type: Form I-485, Application to Register Permanent Residence or Adjust Status
Beneficiary: BENEFICIARY

Notification of Medical Service Requirements for
National Interest Waiver Physicians
Applying for Adjustment of Status - OMB Control Number 1615-0063
Expiration Date 07/31/2022
The record shows that you filed Form I-485 (Application to Register Permanent Residence or Adjust Status)
based on a Form I-140 (Immigrant Petition for Alien Worker) that was approved under Section
203(b)(2)(B)(ii)(I) of the Immigration and Nationality Act (INA), as amended by the Nursing Relief for
Disadvantaged Areas Act (Nursing Relief Act) of 1999. This notice indicates the dates upon which additional
evidence is due to be submitted to this office.

Please use the enclosed cover sheets to submit evidence or correspondence in support
of your application.
This is a summary of the information related to your application:
Form I-140 (Immigrant Petition for Alien Worker) was filed on:
Form I-140 (Immigrant Petition for Alien Worker) was approved on:
Form I-485 (Application to Register Permanent Residence or Adjust Status) was filed on:
Service records indicate that your qualifying medical service began on:

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1. YOU MUST SUBMIT EVIDENCE TO ESTABLISH THAT YOU COMPLETED YOUR QUALIFYING
MEDICAL SERVICE WITHIN 120 DAYS AFTER COMPLETING THE REQUIRED SERVICE. Your
application for adjustment of status will be considered ready for processing after you submit evidence of the
completion of your required medical service. (If you must complete medical service based on a waiver of the
foreign residence requirement of section 212(e) of the INA, please submit evidence of this service at this time
also.)
2. PROOF OF CONTINUED COMPLIANCE WITH THE MEDICAL SERVICE REQUIREMENT:
You must submit evidence that you are in the process of completing your medical service requirement within
120 days after the second and sixth anniversaries of the date your Form I-140 was approved.
You must submit evidence that you are continuing to perform qualifying medical service prior to
_____________ and prior to _______________.
3. ACCEPTABLE EVIDENCE OF QUALIFYING MEDICAL SERVICE:
a) Employment documentation such as individual federal income tax returns and W-2 forms for the
qualifying period.
b) Documentation from your employer(s) attesting to the full-time medical service rendered during
the required aggregate period, to include the date on which you began the medical service (such
documentation to address any breaks in employment other than routine breaks.)
c) Documentation which demonstrates the establishment of a practice, to include the Articles of
Incorporation, business licensure; corporate or other business income tax returns, to include tax
withholding documents for the required period.
d) Any other credible documentation which independently confirms your medical service of the
required period.
e) Evidence which confirms that you have had authorization from U.S. Citizenship and Immigration
Services for all employment during the required period.
f) Evidence which shows that your employment occurred in a geographic area that is (or was when
the employment began) designated by the HHS as having a shortage of health care professionals.
4. FAILURE TO SUBMIT EVIDENCE OF YOUR CONTINUED MEDICAL SERVICE:
Your application for adjustment of status may be considered for denial if you fail to submit evidence that
shows you are in the process of completing your qualifying medical service.
5. EMPLOYMENT AUTHORIZATION RENEWAL:
You may be required to submit evidence to show that you are in the process of completing your qualifying
medical service when you submit Form I-765 for renewal of an Employment Authorization Document. If the
evidence submitted shows that you are not in the process of completing your qualifying medical service, your
Form I-765 may be denied. In addition, your Form I-485 may be considered for denial and your Form I-140
may be considered for revocation of approval. You may submit this evidence along with your Form I-765, or
evidence may be requested by USCIS through a “Request for Evidence” on the I-765.

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Paperwork Reduction Act Burden Disclosure Notice
An agency may not conduct or sponsor an information collection, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB Control Number. The public reporting
burden for this collection of information is estimated to be 1 hour per response, including the time for
reviewing the instructions and completing and submitting the form. Send comments regarding the burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden,
to U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and
Strategy, 20 Massachusetts Ave NW, Washington, DC, 20529-2020; OMB Control Number 16115-0063. Do
not mail your information supporting your request under this OMB Control Number to this address.
DHS Privacy Notice
I-140
AUTHORITIES: The information requested on this petition, and the associated evidence, is collected under
the Immigration and Nationality Act (INA) sections 203(b)(1), 203(b)(2) or 203(b)(3), and 8 U.S.C. sections
1153(b)(1), (b)(2), and (b)(3).
PURPOSE: The primary purpose for providing the requested information on this petition form is to petition
for an immigrant visa based on employment. DHS uses the information you provide to grant or deny the
benefit you are seeking.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested
information, including your Social Security number, and any requested evidence, may delay a final decision or
result in denial of your petition.
ROUTINE USES: DHS may share the information you provide on this form with other Federal, state, local,
and foreign government agencies and authorized organizations. DHS follows approved routine uses described
in the associated published system of records forms [DHS/USCIS/ICE/CBP-001 Alien File, Index, National
File Tracking System, DHS/USCIS-007 Benefits Information System, and DHS/USCIS-018 Immigration
Biometric and Background Check] and published privacy impact assessment [DHS/USCIS/PIA-016(a)
Computer Linked Application Information Management System and Associated Systems], which can be
found at www.dhs.gov/privacy. DHS may also share the information, as appropriate, for law enforcement
purposes or in the interest of national security.