I-817 Application for Family Unity Benefits

Application for Family Unity Benefits

USCIS
Form I-817

Department of Homeland Security
U.S. Citizenship and Immigration Services

DRAFT

OMB No. 1615-0005
Expires 02/28/2026

Fee Stamp

For USCIS Use Only

Action Block

Returned

Initial Application

Valid

Approved

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

From
To

Denied

/
/

NOT

Request for Extension

/
/

Select this box if
Form G-28 is
attached.

► START HERE - Type or print in black ink.

/

/

Approved

Valid

Resubmitted
Received
Relocated
Sent
Remarks

From
To

Denied

/

/

/

/

/

/

Attorney State Bar Number
(if applicable)

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

FOR

NOTE: You must reside and file Form I-817 while in the United States.

Part 1. Information About You (Person
Requesting Family Unity Benefits)
1.

Alien Registration Number (A-Number) (if any)
► A-

Your Full Name

Other Information
5.

Date of Birth (mm/dd/yyyy)

6.

U.S. Social Security Number (if any)
►

7.

USCIS Online Account Number (if any)
►

8.

Sex

9.

Country of Birth

PRODUCTION

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

Male

Female

2.c. Middle Name

Other Names Used

01/30/2024

Provide 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 10.
Additional Information.

10.

Country of Citizenship or Nationality

U.S. Mailing Address
11.a. In Care Of Name (if any)

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

11.b. Street Number
and Name

3.c.

11.c.

Middle Name

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c.

Apt.

Ste.

Flr.

11.d City or Town
11.e. State

11.f. ZIP Code

Middle Name

Form I-817 Edition 04/01/24

Page 1 of 11

Part 1. Information About You (Person
Requesting Family Unity Benefits) (continued)

1.c.

On December 1, 1988, I was the spouse of an alien
who was legalized as a Special Agricultural Worker
under INA section 210.

U.S. Physical Address

1.d.

On December 1, 1988, I was the unmarried child
under 21 years of age of an alien who was a legalized
alien as a Special Agricultural Worker under INA
section 210.

1.e.

On May 5, 1988, I was the spouse of a legalized
alien who adjusted status under section 202 of the
Immigration Reform and Control Act of 1986
(Cuban/Haitian Adjustment).

DRAFT

12.a. Street Number
and Name
12.b.

Apt.

Ste.

Flr.

12.c. City or Town
12.d. State

NOT

12.e. ZIP Code

1.f.

On May 5, 1988, I was the unmarried child under
21 years of age of a person who adjusted status
under section 202 of the Immigration Reform and
Control Act of 1986 (Cuban/Haitian Adjustment).

1.g.

I am the spouse of a person who is eligible for and
has filed or adjusted status under section 1104 of
Public Law (Pub. L.) 106-553, the Legal
Immigration Family Equality (LIFE) Act. I entered
the United States on or before December 1, 1988,
and resided in the United States on that date.

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

FOR
1.h.

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
3.

Height

4.

Weight

5.

Eye Color (Select only one box)

6.

Feet

Inches

PRODUCTION
Pounds

Black
Gray

Blue

Brown

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Black
Gray
White

Unknown/Other

I am applying for Family Unity benefits because: (Select
only one box)

1.b.

NOTE: To be eligible for Immigration Act of 1990
(IMMACT 90) Family Unity Program benefits, your
qualifying spouse or parent must have maintained his or her
status as a legalized alien or as a U.S. citizen, if he or she
naturalized. If deceased, he or she must have maintained
status until his or her death. For LIFE Act Family Unity, your
spouse or parent must be eligible for adjustment or have
adjusted status under section 1104 of the LIFE Act. If you
previously qualified for LIFE Act Family Unity, you may be
eligible to apply for IMMACT 90 Family Unity Program
Benefits.

01/30/2024
Blond
Red

Part 3. Basis For Application

1.a.

I am the unmarried child under 21 years of age of
a person who had filed an adjustment of status
application or adjusted status under section 1104
of Pub. L. 106-553, the LIFE Act. I entered the
United States on or before December 1, 1988, and
resided in the United States on that date.

On May 5, 1988, I was the spouse of an alien who
was legalized under the Immigration and Nationality
Act (INA) section 245A.

I am requesting: (Select only one box)
2.a.

Initial Family Unity benefits under section 301 of
IMMACT 90.

2.b.

An extension of Family Unity benefits under section
301 of IMMACT 90.

2.c.

Initial Family Unity benefits under section 1504 of
the LIFE Act Amendments.

2.d.

An extension of Family Unity benefits under section
1504 of the LIFE Act Amendments.

On May 5, 1988, I was the unmarried child under 21
years of age of an alien who was legalized under INA
section 245A.

Form I-817 Edition 04/01/24

Page 2 of 11

Part 4. Information About Your Relationship

U.S. Physical Address for Your Spouse or Parent

If you need extra space to complete Part 4., use the space
provided in Part 10. Additional Information.

10.a. Street Number
and Name

DRAFT
10.b.

Apt.

Ste.

Flr.

Information About Your Spouse or Parent
Provide the following information about the legalized alien
through whom you are claiming your eligibility.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

10.c. City or Town
10.d. State

10.e. ZIP Code

NOT
11.

Daytime Telephone Number (if any)

12.

Email Address (if any)

1.c. Middle Name
Other Names Used
Provide all other names the legalized alien has ever used,
including aliases, maiden name, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.

FOR

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

3.c. Middle Name

13. Marital Status
Married

Divorced

Widowed

Separated

Provide the following information about you and your spouse.
14.a. Number of times you have been married (including current
marriage)

2.c. Middle Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

Complete Only if You Are Applying Based on a
Marital Relationship or You Were Previously
Married

14.b. Number of times your spouse has been married (including
spouse's current marriage)

PRODUCTION

If currently married, provide the following information about
your marriage.

4.

Date of Birth (mm/dd/yyyy)

5.

A-Number (if any) ► A-

Place of Marriage

6.

USCIS Online Account Number (if any)

15.b. City or Town

►

15.a. Date of Marriage (mm/dd/yyyy)

01/30/2024

7.

U.S. Social Security Number (if any)
►

8.

Sex

9.

Class of Admission (visitor, student, EWI, etc.)

15.c. State

15.d. Province
Male

Female

15.e. Country

15.f. Type of Ceremony:
15.g. We are:

Religious

Living together

Civil

None

Not living together

15.h. If you selected "Not living together," (select only one box):
My spouse has died
We are separated

Form I-817 Edition 04/01/24

We are divorced

Page 3 of 11

Part 4. Information About Your Relationship
(continued)

Information About Your Spouse's Prior Spouse

DRAFT

Information About Your Prior Marriage
Provide the following information about your prior marriages
(if any).
16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)

Provide the following information about your current spouse's
prior marriages (if any).
18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c. Middle Name

NOT

19.a. Date of Marriage (if any) (mm/dd/yyyy)

16.c. Middle Name

Place of Marriage

17.a. Date of Marriage (if any) (mm/dd/yyyy)

19.b. City or Town

Place of Prior Marriage
19.c. State

17.b. City or Town

FOR

19.d. Province
19.e. Country

17.c. State
17.d. Province

19.f. Date of Termination (mm/dd/yyyy)

17.e. Country

Place of Termination

Place of Termination
17.g. City or Town

19.g. City or Town

PRODUCTION

17.f. Date of Termination (mm/dd/yyyy)

19.h. State

19.i. Province
19.j. Country

17.h. State
17.i. Province

19.k. Reason for Termination
Death
Divorce

01/30/2024

17.j. Country

Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 10. Additional Information.)

17.k. Reason for Termination
Divorce

Death

Annulment

Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 10. Additional Information.)

NOTE: If you were previously married, you must complete
Part 4., Item Numbers 13. - 19.k. of this application; complete
all requested information about your prior marriages; and select
the box in Item Number 20. indicating that it is complete.
20.

Form I-817 Edition 04/01/24

Annulment

I have completed Part 4., Item Numbers 13. - 19.k.,
information about my prior marriages (if any).

Page 4 of 11

If divorced or widowed, provide the following information.

Part 4. Information About Your Relationship
(continued)

DRAFT

24.a. Date of Marriage (mm/dd/yyyy)
Place Marriage Ended

Complete Only if You Are Applying Based on a
Child/Parent Relationship

24.b. City or Town

Indicate how your parent is related to you (Select only one box)
24.c. State

21.a.

Biological mother

21.b.

Biological father who was married to my mother
when I was born

21.c.

Biological father who was not married to my mother
when I was born

21.d.

Stepparent - based on marriage to my parent which
occurred before my 18th birthday

21.e.

NOT

24.d. Province

Adoptive parent (select only one box):

24.e. Country

Part 5. Other Information
1.

A.

The adoption occurred before my 16th birthday.
Yes
No

B.

My adoptive parent had legal custody of me
on May 5, 1988 or December 1, 1988, (as
appropriate), and I resided with him or her for
two years prior to that date.

Have you EVER applied before for the Family Unity
Program?
Yes
No

FOR

Yes

No

If you answered "Yes," provide the following information.

Name Under Which You Applied
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Provide the following information about your marital status.

2.c. Middle Name

22.a. Marital Status
Single, Never Married
Married
Widowed
Separated

Place Where Application Was Filed

PRODUCTION
Divorced

Provide the following information.

2.e. State

23.a. Date of Marriage (mm/dd/yyyy)

2.f.

Place of Marriage

Date Filed (mm/dd/yyyy)

2.g. U.S. Citizenship and Immigration Services (USCIS) (or
former Immigration and Naturalization Service (INS))
action taken on case
Approved
Denied

01/30/2024

23.b. City or Town

3.a. At the time of your last entry into the United States, you
(Select only one box):
Were inspected and admitted
Were inspected and paroled
Entered without inspection

23.c. State
23.d. Province
23.e. Country

23.f. Type of ceremony:
23.g. We are:

2.d. City or Town

Religious

Living together

Civil

None

Not living together

3.b. Date of Last Arrival (mm/dd/yyyy)
3.c. Form I-94 Arrival-Departure Record Number
►

23.h. If you selected "Not living together," (Select only one box):
My spouse has died
We are divorced
We are separated
Form I-817 Edition 04/01/24

Page 5 of 11

Part 5. Other Information (continued)

6.d. A-Number (if any) ► A-

3.d. Passport Number

6.e. Relationship to Applicant

DRAFT

3.e. Travel Document Number
3.f.

Country of Issuance for Passport or Travel Document

3.g. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
3.h. Current or Most Recent Immigration Status

7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)
7.c. Middle Name

NOT

7.d. A-Number (if any) ► A7.e. Relationship to Applicant

3.i.

Date Status Expires (mm/dd/yyyy)

3.j.

Date Continuous U.S. Residence Began (mm/dd/yyyy)

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

FOR

Provide the U.S. address where you lived on May 5, 1988 (INA
section 245A or Cuban Haitian Adjustment Act) or December
1, 1988 (INA section 210 or LIFE Act).

8.d. A-Number (if any) ► A-

4.a. Street Number
and Name
4.b.

Apt.

8.c. Middle Name

Ste.

8.e. Relationship to Applicant

Flr.

4.c. City or Town
4.e. ZIP Code

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

If you are submitting separate applications for Family Unity
benefits at this time for other relatives, provide the following
information about those other relatives.

9.c. Middle Name

NOTE: If you need extra space to complete an answer in Item
Numbers 5.a. - 24.f., use the space provided in Part 10.
Additional Information..

9.e. Relationship to Applicant

4.d. State

PRODUCTION

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
5.d. A-Number (if any) ► A5.e. Relationship to Applicant

9.d. A-Number (if any) ► A-

01/30/2024
10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)

10.c. Middle Name
10.d. A-Number (if any) ► A10.e. Relationship to Applicant

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Middle Name

Form I-817 Edition 04/01/24

Page 6 of 11

Part 5. Other Information (continued)

Previous Residence 1

List all absences from the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Form I-817,
whichever date is later.

19.a. Street Number
and Name

DRAFT
19.b.

Apt.

Ste.

Flr.

19.c. City or Town

11.a. Departure Date (mm/dd/yyyy)

19.d. State

11.b. Return Date (mm/dd/yyyy)

19.e. ZIP Code

NOT

19.f. Dates of Residence (mm/dd/yyyy)
From
To

12.a. Departure Date (mm/dd/yyyy)
12.b. Return Date (mm/dd/yyyy)

Previous Residence 2

13.a. Departure Date (mm/dd/yyyy)

20.a. Street Number
and Name

13.b. Return Date (mm/dd/yyyy)

20.b.

Apt.

FOR

Ste.

Flr.

20.c. City or Town

14.a. Departure Date (mm/dd/yyyy)

20.d. State

14.b. Return Date (mm/dd/yyyy)

20.e. ZIP Code

20.f. Dates of Residence (mm/dd/yyyy)
From
To

15.a. Departure Date (mm/dd/yyyy)
15.b. Return Date (mm/dd/yyyy)

Previous Residence 3

16.a. Departure Date (mm/dd/yyyy)

21.a. Street Number
and Name

16.b. Return Date (mm/dd/yyyy)

21.b.

PRODUCTION
Apt.

Ste.

Flr.

21.c. City or Town

17.a. Departure Date (mm/dd/yyyy)

21.d. State

17.b. Return Date (mm/dd/yyyy)

21.e. ZIP Code

21.f. Dates of Residence (mm/dd/yyyy)
List all residences in the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Family Unity
application (Form I-817), whichever date is later.

Previous Residence 4

Current Residence

22.a. Street Number
and Name

18.a. Street Number
and Name

22.b.

From

To

01/30/2024

18.b.

Apt.

Ste.

Flr.

22.d. State

Form I-817 Edition 04/01/24

Flr.

22.e. ZIP Code

22.f. Dates of Residence (mm/dd/yyyy)

18.e. ZIP Code

18.f. Dates of Residence (mm/dd/yyyy)
From
To

Ste.

22.c. City or Town

18.c. City or Town
18.d. State

Apt.

From

To

Present

Page 7 of 11

Part 5. Other Information (continued)

Have you EVER:

Previous Residence 5

26.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
Yes
No

DRAFT

23.a. Street Number
and Name
23.b.

Apt.

Ste.

26.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No

Flr.

23.c. City or Town
23.d. State

NOT

23.e. ZIP Code

23.f. Dates of Residence (mm/dd/yyyy)
From
To

Previous Residence 6

27.

Have you EVER been a member of, assisted in, or
participated in any group, unit or organization of any kind
in which you or other persons used any type of weapon
against any person or threatened to do so?
Yes
No

28.

Have you EVER assisted or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
Yes
No

24.a. Street Number
and Name
24.b.

Apt.

Ste.

FOR

Flr.

24.c. City or Town
24.d. State

29.

24.e. ZIP Code

24.f. Dates of Residence (mm/dd/yyyy)
From
To

Have you EVER received any type of military,
paramilitary, or weapons training?
Yes

No

Have you EVER in the United States or Abroad:
30.a. Engaged in, conspired to engage in, or intended to engage
in a terrorist activity with intent to cause death or serious
bodily harm?
Yes
No

PRODUCTION

NOTE: If you need extra space to complete an answer in Item
Numbers 5.a. - 24.f., use the space provided in Part 10.
Additional Information.
Answer Item Numbers 25.a. - 38. If you answer “Yes” to
ANY of the questions, use the space provided in Part 10.
Additional Information to provide an explanation.

30.b. Been a representative of a terrorist organization or a
member of an organization which you knew or should have
known is a terrorist organization?
Yes
No
31.

Have you EVER ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:

Have you EVER engaged in any activity to violate any
law of the United States related to espionage or sabotage
or to violate or evade any law prohibiting the export from
the United States of goods, technology, or sensitive
information?
Yes
No

01/30/2024

25.a. Acts involving torture or genocide?

Yes

No

25.b. Killing any person?

Yes

No

25.c. Intentionally and severely injuring any person?
Yes

25.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes

Form I-817 Edition 04/01/24

32.a. Been convicted by a final judgment of a particularly
serious crime?
Yes
No

No

25.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes

Have you EVER:

No

No

32.b. Participated in any other criminal activity which
endangers public safety or national security of the
United States?
Yes
33.

No

Have you EVER been convicted of any offenses for
which the aggregate sentences were five or more years
of confinement?
Yes
No

Page 8 of 11

Part 5. Other Information (continued)

Applicant's Certification and Signature

DRAFT

34.

Have you EVER been ordered deported, excluded, or
removed from the United States as you were inadmissible
at the time of entry or of adjustment of status, or violated
status?
Yes
No

35.

Have you EVER been convicted of a felony crime of
violence that has an element of or attempted use of
physical force against another individual in the course of
committing the offense?
Yes
No

36.

Have you EVER engaged in genocide, or ordered, incited,
assisted or otherwise participated in the persecution of
any person because of race, religion, national origin,
membership in a particular social group, or political
opinion?
Yes
No

I certify, under penalty of perjury, that I provided or authorized
all of the responses and information contained in and submitted
with my application, I read and understand or, if interpreted to
me in a language in which I am fluent by the interpreter listed in
Part 7., understood, all of the responses and information
contained in, and submitted with, my application, and that all of
the responses and the information are complete, true, and
correct. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for an immigration request and to other
entities and persons where necessary for the administration and
enforcement of U.S. immigration law.

NOT

37.

Have you EVER committed a serious nonpolitical crime
outside the United States before you arrived in the United
States?
Yes
No

38.

Have you EVER been convicted of a felony or three or
more misdemeanors in the United States?

4.a. Applicant's Signature

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

FOR

Yes

No

Part 7. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Full Name

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

Part 6. Applicant's Contact Information,
Certification and Signature

PRODUCTION

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

Applicant's Contact Information

Provide your daytime telephone number, mobile telephone
number (if any), and email address (if any).
1.

Applicant's Daytime Telephone Number

2.

Applicant's Mobile Telephone Number (if any)

3.

Applicant's Email Address (if any)

Form I-817 Edition 04/01/24

2.

Interpreter's Business or Organization Name

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

01/30/2024
4.

Interpreter's Mobile Telephone Number (if any)

5.

Interpreter's Email Address (if any)

Page 9 of 11

Part 7. Interpreter's Contact Information,
Certification, and Signature (continued)

Preparer's Certification and Signature

DRAFT

Interpreter's Certification and Signature
I certify, under penalty of perjury, that I am Fluent in English
,
and
and I have interpreted every question on the application and
Instructions and interpreted the applicant's answers to the
questions in that language, and the applicant informed me that
they understood every instruction, question, and answer on the
application.

I certify, under penalty of perjury, that I prepared this
application for the applicant at their request and with express
consent and that all of the responses and information contained
in and submitted with the application are complete, true, and
correct and reflects only information provided by the applicant.
The applicant reviewed the responses and information and
informed me that they understand the responses and information
in or submitted with the application.

NOT

6.a. Preparer's Signature

6.a. Interpreter's Signature

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

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

Part 9. Signature for Placement On Employment
Authorization Document
Provide your signature below. This signature will be scanned
and duplicated for placement on your Employment
Authorization Document. When signing, make sure that no
part of your signature goes outside the lines of the box.

FOR

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing This
Application, if Other Than the Applicant

Signature

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

PRODUCTION

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

2.

Preparer's Business or Organization Name

Preparer's Contact Information

01/30/2024

3.

Preparer's Daytime Telephone Number

4.

Preparer's Mobile Telephone Number (if any)

5.

Preparer's Email Address (if any)

Form I-817 Edition 04/01/24

Page 10 of 11

Part 10. Additional Information

5.a. Page Number

DRAFT

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.

NOT

Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

6.a. Page Number

3.b. Part Number

FOR

3.c. Item Number

6.d.

3.d.

PRODUCTION
7.a. Page Number
4.a. Page Number

7.b. Part Number

7.c. Item Number

01/30/2024

4.b. Part Number

4.c. Item Number

7.d.

4.d.

Form I-817 Edition 04/01/24

Page 11 of 11