Form I-90 Application to Replace Permanent Resident Card

Application to Replace Permanent Resident Card
Department of Homeland Security
U.S. Citizenship and Immigration Services
Applicant Interviewed

USCIS
Form I-90
OMB No. 1615-0082
Expires 07/31/2019

Receipt

Action Block

Date:
For
USCIS
Use
Only

Class of Admission

Remarks

DRAFT

To be completed
by an attorney
or BIA-accredited
representative (if any).

Select this box if
Form G-28 is
attached to
represent the
applicant.

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You
1.

2.

NOT FOR

Alien Registration Number (A-Number)

A-

If your name has legally changed since the issuance of your
Permanent Resident Card, provide your name exactly as it
is printed on your current Permanent Resident Card.

USCIS Online Account Number (if any)

NOTE: Include all evidence of your legal name change with
this application.

Your Full Name

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

NOTE: Your card will be issued in this name.

5.c. Middle Name

►

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

PRODUCTION
Mailing Address

(USPS ZIP Code Lookup)

6.a. In Care Of Name

3.c. Middle Name
4.

Has your name legally changed since the issuance of your
Permanent Resident Card?

6.b. Street Number
and Name
6.c.

Apt.

Ste.

07/17/2019

Yes (Proceed to Item Numbers 5.a. - 5.c.)
No (Proceed to Item Numbers 6.a. - 6.i.)
N/A - I never received my previous card.
(Proceed to Item Numbers 6.a. - 6.i.)

Flr.

6.d. City or Town
6.e. State

6.f.

ZIP Code

6.g. Province
6.h. Postal Code
6.i.

Form I-90 02/27/17

Country

Page 1 of 7

Part 1. Information About You (continued)

Physical Address
Provide this information only if different than mailing address.

Port-of-Entry Commuters
All commuters (those who currently have commuter status and
those who are taking up commuter status) who provided a
foreign mailing address in Item Numbers 6.a. - 6.i., need to
provide the U.S. port-of-entry (POE) where you will pick up
your card:
7.

9.a. Street Number
and Name
9.b.

Apt.

9.f.
NOTE: If the city or town has more than one POE, include
additional information (such as an airport, bridge, or tunnel
name) to assist U.S. Citizenship and Immigration Services
(USCIS) in identifying which POE to mail your card.

Flr.

9.c. City or Town
9.d. State

City or Town and State

Ste.

9.e. ZIP Code

Province

9.g. Postal Code

DRAFT
9.h. Country

Alternate or Safe Mailing Address
If you filed an adjustment of status application based on the
Violence Against Women Act (VAWA) or as a human
trafficking victim (T nonimmigrant), or victim of a qualifying
crime (U nonimmigrant) and you do not want USCIS to send
notices about this application to your home, you may provide a
safe mailing address. If you are applying as a special immigrant
juvenile, you may provide an alternate mailing address.

Additional Information
10.

Gender

Male

11.

Date of Birth

(mm/dd/yyyy)

12.

City/Town/Village of Birth

13.

Country of Birth

14.

Class of Admission

Female

NOT FOR

8.a. In Care Of Name

8.b. Street Number
and Name
8.c.

Apt.

Ste.

8.d. City or Town
8.e. State

8.f.

Flr.

PRODUCTION
15.

Date of Admission (mm/dd/yyyy)

16.

U.S. Social Security Number (if any)

ZIP Code

►

8.g. Province

Parent 1 Legal Name

8.h. Postal Code

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

8.i.

Country

07/17/2019
17.c. Middle Name

Parent 2 Legal Name
18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c. Middle Name

Form I-90 02/27/17

Page 2 of 7

Part 2. Application Type

2.h.1.

I am a permanent resident who is taking up commuter
status.

Reason for Application (Select only one box)

2.h.2.

I am a commuter who is taking up actual residence in
the United States.

2.i.

I have been automatically converted to lawful
permanent resident status.

2.j.

I have a prior edition of the alien registration card.

2.k.

I am applying to replace my current Permanent
Resident Card for any other reason that is not
specified above. Provide a detailed explanation of the
reason you are applying to replace your card in the
space provided in Part 7. Additional Information.

NOTE: If your conditional permanent resident status is
expiring within the next 90 days, then do not file this
application. (See the What is the Purpose of Form I-90
section of the Form I-90 Instructions for further information.)
My status is (Select only one box):
1.a.

Lawful Permanent Resident (Proceed to Section A.)

1.b.

Permanent Resident - In Commuter Status
(Proceed to Section A.)

1.c.

Conditional Permanent Resident
(Proceed to Section B.)

DRAFT

Section A. (Complete this section only if you are a lawful
permanent resident or a permanent resident in commuter status.)
2.a.

My previous card has been lost, stolen, or destroyed.

2.b.

My previous card was issued but never received.

2.c.

My existing card has been mutilated.

2.d.

My existing card has incorrect data because of
Department of Homeland Security (DHS) error.
(Provide a detailed explanation of the error in the
space provided in Part 7. Additional Information
and return your existing card with incorrect data
along with this application.)

2.e.

My name or other biographic information has legally
changed since issuance of my existing card or my card
has incorrect data and the error was not caused by
DHS. (Provide a detailed explanation of the
biographic information that changed or the error in the
space provided in Part 7. Additional Information,
and include appropriate documentary evidence that
reflects the change or new data.)

Section B. Complete this section only if you are a conditional
permanent resident. If your conditional permanent resident status
is expiring within the next 90 days, then do not file this
application. (See the What is the Purpose of Form I-90 section
of the Form I-90 Instructions for further information.)
3.a.

My previous card has been lost, stolen, or destroyed.

3.b.

My previous card was issued but never received.

3.c.

My existing card has been mutilated.

3.d.

My existing card has incorrect data because of DHS
error. (Provide a detailed explanation of the error in
the space provided in Part 7. Additional
Information and return your existing card with
incorrect data along with this application.)

3.e.

My name or other biographic information has legally
changed since the issuance of my existing card or my
card has incorrect data and the error was not caused
by DHS. (Provide a detailed explanation of the
biographic information that changed or the error in
the space provided in Part 7. Additional
Information, and include appropriate documentary
evidence that reflects the change or new data.)

NOT FOR

PRODUCTION

2.f.

My existing card has already expired or will expire
within six months.

2.g.1.

I have reached my 14th birthday and am registering
as required. My existing card will expire AFTER my
16th birthday. (See NOTE below for additional
information.)

Part 3. Processing Information
1.

Location where you applied for an immigrant visa or
adjustment of status:

07/17/2019

2.g.2.

I have reached my 14th birthday and am registering
as required. My existing card will expire BEFORE
my 16th birthday. (See NOTE below for additional
information.)

2.

Location where your immigrant visa was issued or USCIS
office where you were granted adjustment of status:

NOTE: If you are filing this application before your
14th birthday, or more than 30 days after your 14th
birthday, you must select reason 2.k. However, if
your card has expired, you must select reason 2.f.

Form I-90 02/27/17

Page 3 of 7

Part 3. Processing Information (continued)

Biographic Information

Complete Item Numbers 3.a. and 3.a.1. if you entered the
United States with an immigrant visa. (If you were granted
adjustment of status, proceed to Item Number 4.)

12.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

13.

Race (Select all applicable boxes)

3.a. Destination in the United States at time of admission:

American Indian or Alaska Native
Asian

3.a.1. Port-of-Entry where admitted to the United States:

Black or African American

City or Town and State

Answer Item Numbers 4. - 11. If you answer "Yes" to any
question (or if you answer “No,” but are unsure of your answer),
provide a detailed explanation in the space provided in Part 7.
Additional Information.
4.

DRAFT

Have you ever been in exclusion, deportation, or removal
proceedings or ordered removed from the United States?
Yes

5.

Native Hawaiian or Other Pacific Islander
White
14.

Height

15.

Weight

16.

Eye Color (Select only one box)

No

Since you were granted permanent resident status, have
you ever filed or signed a Form I-407, Record of
Abandonment of Lawful Permanent Resident Status, or
any other document indicating you have abandoned your
permanent resident status?
Yes
No

17.

Feet

Pounds

Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)

NOT FOR

6.

Since you were granted permanent resident status, have
you ever been determined by a judge to have abandoned
your permanent resident status?
Yes
No

7.

Since you were granted permanent resident status, have
you ever been absent from the United States for a
continuous period for more than 180 days but less than
one year?
Yes
No

8.

Bald (No hair)
Brown
Sandy

Black
Gray
White

Blond
Red
Unknown/Other

Part 4. Applicant's Statement, Contact
Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-90
Instructions before completing this section.

PRODUCTION

Since you were granted permanent resident status, have
you ever been absent from the United States for a
continuous period of one year or more?
Yes
No

9.

Since you were granted permanent resident status, have
you ever had a residence outside the United States, other
than while you held commuter status?
Yes
No

10.

Since you were granted permanent resident status, have
you ever been employed outside the United States, other
than while you held commuter status?
Yes
No

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.
1.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.

07/17/2019
1.b.

NOTE: Only answer Item Number 11. if you hold or have
held commuter status.
11.

Inches

Were you ever out of regular employment in the U.S. for
a continuous period of six months or more while you held
commuter status?
Yes
No

The interpreter named in Part 6. 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.
,

a language in which I am fluent and I understood
everything.
2.

At my request, the preparer named in Part 7.,
,
prepared this application for me based only upon
information I provided or authorized.

Form I-90 02/27/17

Page 4 of 7

Part 5. Interpreter's Contact Information,
Certification, and Signature

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

Provide the following information about the interpreter.

Applicant's Contact Information

Interpreter's Full Name

3.

Applicant's Daytime Telephone Number

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

4.

Applicant's Mobile Telephone Number (if any)

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

5.

Applicant's Email Address (if any)

2.

Applicant's Certification

Interpreter's Business or Organization Name (if any)

DRAFT

Interpreter's Mailing Address

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.

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town

NOT FOR

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 will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:

3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

PRODUCTION

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.

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)

07/17/2019

Interpreter's Certification

Applicant's Signature
6.a. Applicant's Signature

6.b. 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 may deny your application.
Form I-90 02/27/17

I certify, under penalty of perjury, that:
I am fluent in English and

,

which is the same language provided in Part 5., Item Number
1.b., 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.
Page 5 of 7

Part 5. Interpreter's Contact Information,
Certification, and Signature (continued)

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.

7.b.

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

I am an attorney or accredited representative and my
representation of the applicant in this case
does not extend beyond the
extends
preparation of this application.

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

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.

Interpreter's Signature
7.a. Interpreter's Signature

DRAFT

Provide the following information about the preparer.

Preparer's Certification

Preparer's Full Name

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.

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

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

2.

NOT FOR

Preparer's Business or Organization Name (if any)

Preparer's Signature
Preparer's Mailing Address

8.a. Preparer's Signature

3.a. Street Number
and Name
3.b.

Apt.

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

Ste.

PRODUCTION

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

Flr.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

07/17/2019

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-90 02/27/17

Page 6 of 7

5.a. Page Number

Part 7. 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.

5.b. Part Number

5.c. Item Number

6.b. Part Number

6.c. Item Number

5.d.

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

DRAFT

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d.

6.a. Page Number

6.d.

NOT FOR
PRODUCTION
4.a. Page Number

4.d.

4.b. Part Number

4.c. Item Number

7.a. Page Number

7.b. Part Number

7.c. Item Number

7.d.

07/17/2019

Form I-90 02/27/17

Page 7 of 7