I-483 Frm

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TABLE OF CHANGES – FORM

Form I-485, Application to Register Permanent Residence or Adjust Status

OMB Number: 1615-0023

09/03/2024

Reason for Revision: Comprehensive Review

Project Phase: OMB Review

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Expires 03/31/2027

Edition Date 08/28/2024

Current Page Number and Section	Current Text	Proposed Text
Page 1	[Page 1] Preference Category: Country Chargeable: Priority Date: Date Form I-693 Received: Applicant Interviewed Interview Waived Date of Initial Interview: Lawful Permanent Resident as of: Receipt Section of Law INA 209(a) INA 209(b) INA 245(a) INA 245(i) INA 245(m) INA 249 Sec. 13, Act of 9/11/57 Cuban Adjustment Act Other Action Block	[Page 1] Preference Category: Country Chargeable: Priority Date: Date Form I-693 Signed By Civil Surgeon: Applicant Interviewed Interview Waived Date of Initial Interview: Lawful Permanent Resident as of: Receipt Section of Law INA 209(a) INA 209(b) INA 245(a) INA 245(i) INA 245(j) INA 245(m) INA 249 Sec. 13, Act of 9/11/57 Cuban Adjustment Act Other Action Block
Page 1	[Page 1] To be completed by an attorney or accredited representative (if any). Select this box if Form G-28 is attached. Volag Number (if any) Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink. A-Number [Fillable field that auto-populates at the top of each subsequent page] NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, U.S. Citizenship and Immigration Services (USCIS) may deny your application.	[Page 1] To be completed by an Attorney or Accredited Representative (if any). [no change] NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, U.S. Citizenship and Immigration Services (USCIS) may reject or deny your application. For all sections of this application, if you need to provide any additional information or are instructed to provide an explanation, use the space provided in Part 14. Additional Information.
Page 1-3, Part 1. Information About You (Person applying for lawful permanent residence)	[Page 1] Part 1. Information About You (Person applying for lawful permanent residence) Your Current Legal Name (do not provide a nickname) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Other Names You Have Used Since Birth (if applicable) NOTE: Provide all other names you have ever used, including your family name at birth, other legal names, nicknames, aliases, and assumed names. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Information About You 5. Date of Birth (mm/dd/yyyy) NOTE: In addition to providing your actual date of birth, include any other dates of birth you have used in connection with any legal names or non-legal names in the space provided in Part 14. Additional Information. [Page 2] 10. Alien Registration Number (A-Number) (if any) [Page 1] 6. Sex Male Female 7. City or Town of Birth [Page 2] 8. Country of Birth 9. Country of Citizenship or Nationality NOTE: If you have EVER used other A-Numbers, include the additional A-Numbers in the space provided in Part 14. Additional Information. 11. USCIS Online Account Number (if any) Recent Immigration History Provide the information for Item Numbers 18. - 24. if you last entered the United States using a passport or travel document. 18. Passport Number Used at Last Arrival 19. Travel Document Number Used at Last Arrival 20. Expiration Date of this Passport or Travel Document (mm/dd/yyyy) 21. Country that Issued this Passport or Travel Document 22. Nonimmigrant Visa Number from this Passport (if any) Place of Last Arrival into the United States 23.a. City or Town 23.b. State 24. Date of Last Arrival (mm/dd/yyyy) [Page 3] When I last arrived in the United States, I: 25.a. Was inspected at a port of entry and admitted as (for example, exchange visitor; visitor, waived through; temporary worker; student): [Fillable field] 25.b. Was inspected at a port of entry and paroled as (for example, humanitarian parole, Cuban parole): [Fillable field] 25.c. Came into the United States without admission or parole. 25.d. Other: [Fillable field] If you were issued a Form I-94 Arrival-Departure Record Number: Provide your name exactly as it appears on your Form I-94 (if any) 28.a. Family Name (Last Name) 28.b. Given Name (First Name) 28.c. Middle Name 26.a. Form I-94 Arrival-Departure Record Number 26.b. Expiration Date of Authorized Stay Shown on Form I-94 (mm/dd/yyyy) 26.c. Status on Form I-94 (for example, class of admission, or paroled, if paroled) 27. What is your current immigration status (if it has changed since your arrival)? [Page 2] U.S. Mailing Address 12.a. In Care Of Name (if any) 12.b. Street Number and Name 12.c. Apt./Ste./Flr. [Fillable field] 12.d. City or Town 12.e. State 12.f. ZIP Code Alternate and/or Safe Mailing Address If you are applying based on the Violence Against Women Act (VAWA) or as a special immigrant juvenile, 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 an alternative and/or safe mailing address. 13.a. In Care Of Name (if any) 13.b. Street Number and Name 13.c. Apt./Ste./Flr. [Fillable field] 13.d. City or Town 13.e. State 13.f. ZIP Code Social Security Card 14. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? Yes No If you answered “Yes,” provide the information requested in Item Number 15. 15. Provide your U.S. Social Security Number (SSN). 16. Do you want the SSA to issue you a Social Security card? (You must also answer “Yes” to Item Number 17. Consent for Disclosure, to receive a card). Yes No 17. Consent for Disclosure: I authorize disclosure of information from this application to the SSA as required for the purpose of assigning me an SSN and issuing me a Social Security Card. Yes No	[Page 1] Part 1. Information About You (Person applying for lawful permanent residence) 1. Your Current Legal Name (Do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 2. Other Names You Have Used Since Birth (if applicable) Provide all other names you have ever used, including your family name at birth, other legal names, nicknames, aliases, and assumed names. Family Name (Last Name) x2 Given Name (First Name) x2 Middle Name (if applicable) x2 [delete] 3. Date of Birth (mm/dd/yyyy) Have you ever used any other date of birth? Yes No If you answered “Yes,” provide all other dates of birth (mm/dd/yyyy). [DOB field] x 2 [deleted] [Page 2] 4. Do you have an Alien Registration Number (A-Number)? Yes No If you answered “Yes,” provide your A-Number. A-Number (if any) 5. Have you ever used, or been assigned, any other A-Number? Yes No If you answered “Yes,” provide the A-Numbers. A-Number x 2 6. Gender Male Female Another Gender Identity 7. Place of Birth City or Town of Birth Country of Birth 8. Country of Citizenship or Nationality [delete] 9. USCIS Online Account Number (if any) If one has been assigned, you can find it on a notice that USCIS may have sent to you. 10. Recent Immigration History If you last entered the United States using a passport or travel document, provide the following information. Passport or Travel Document Number Used at Last Arrival Expiration Date of this Passport or Travel Document (mm/dd/yyyy) Country that Issued this Passport or Travel Document Nonimmigrant Visa Number Used During Most Recent Arrival (if any) Date Nonimmigrant Visa Was Issued (mm/dd/yyyy) Place and Date of Last Arrival into the United States City or Town State Date of Last Arrival (mm/dd/yyyy) 11. When I last arrived in the United States: [ ] I was inspected at a Port of Entry and admitted as (for example, exchange visitor, visitor, temporary worker, student): [Fillable field] [ ] I was inspected at a Port of Entry and paroled as (for example, humanitarian parole, Cuban parole): [Fillable field] [ ] I came into the United States without admission or parole. [ ] Other: [Fillable field] [Page 3] 12. If you were issued a Form I-94 Arrival/Departure Record, provide the information from your most recent Form I-94 below: [delete] Family Name (Last Name) Given Name (First Name) [delete] Form I-94 Arrival/Departure Record Number Expiration Date of Authorized Stay Shown on Form I-94 or Type or Print “D/S” for Duration of Status (mm/dd/yyyy) Immigration Status on Form I-94 (for example, class of admission, or paroled, if paroled) 13. Was your last arrival the first time you were physically present in the United States? Yes No 14. What is your current immigration status (if it has changed since your last arrival)? 15. Expiration Date of Current Immigration Status or Type or Print “D/S” for Duration of Status (mm/dd/yyyy) 16. Have you ever been issued an “alien crewman” visa? Yes No 17. Did you last arrive in the United States to join a vessel as a seaman or crewman, or while serving in any capacity aboard a vessel or aircraft? Yes No 18. Addresses Current U.S. Physical Address In Care Of Name (if any) Street Number and Name Apt./Ste./Flr. [Fillable field] City or Town State ZIP Code Date You First Resided at This Address (mm/dd/yyyy) Is this your current mailing address? Yes No If you answered “No,” provide your current mailing address. Current Mailing Address (Safe or Alternate Mailing Address, if applicable) In Care Of Name (if any) Street Number and Name Apt./Ste./Flr. [Fillable field] City or Town State ZIP Code [Page 4] Have you resided at your current address for at least 5 years? Yes No If you answered “No,” provide your prior address(es) for the last 5 years. Use the space provided in Part 14. Additional Information, if necessary. Prior Address In Care Of Name (if any) Street Number and Name Apt./Ste./Flr. [Fillable field] City or Town State ZIP Code Province Postal Code Country Dates of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Most Recent Address Outside the United States Provide your most recent physical address outside the United States where you lived for more than one year (if not already listed above). Street Number and Name Apt./Ste./Flr. [Fillable field] City or Town State ZIP Code Province Postal Code Country Dates of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) 19. Social Security Card Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? Yes No If you answered “Yes,” provide your U.S. Social Security Number (SSN). [SSN field] Do you want the SSA to issue you a Social Security card? Yes No If you answered “Yes,” you must also answer “Yes” to the Consent for Disclosure below. Consent for Disclosure: I authorize disclosure of information from this application to the SSA as required for the purpose of assigning me an SSN and issuing me a Social Security Card. Yes No
Page 3-4, Part 2. Application Type or Filing Category	[Page 3] Part 2. Application Type or Filing Category NOTE: Attach a copy of the Form I-797 receipt or approval notice for the underlying petition or application, as appropriate. I am applying to register lawful permanent residence or adjust status to that of a lawful permanent resident based on the following immigrant category (select only one box). (See the Form I-485 Instructions for more information, including any Additional Instructions that relate to the immigrant category you select.): 1.a. Family-based [] Immediate relative of a U.S. citizen, Form I-130 [] Person admitted to the United States as a fiancé(e) or child of a fiancé(e) of a U.S. citizen, Form I-129F (K-1/K-2 Nonimmigrant) [] Widow or widower of a U.S. citizen, Form I-360 [] Other relative of a U.S. citizen or relative of a lawful permanent resident under the family-based preference categories, Form I-130 [] VAWA self-petitioner, Form I-360 1.b. Employment-based [] Alien entrepreneur, Form I-526 [] Alien worker, Form I-140 1.c. Special Immigrant [] Special immigrant juvenile, Form I-360 [] Certain Afghan or Iraqi National, Form I-360 or Form DS-157 [] Certain international broadcaster, Form I-360 [] Certain G-4 international organization or family member or NATO-6 employee or family member, Form I-360 [] Religious worker, Form I-360 1.d. Asylee or Refugee [] Asylum status (INA section 208), Form I-589 or Form I-730 [] Refugee status (INA section 207), Form I-590 or Form I-730 1.e. Human Trafficking Victim or Crime Victim [] Human trafficking victim (T Nonimmigrant), Form I-914 or derivative family member, Form I-914A [] Crime victim (U Nonimmigrant), Form I-918, derivative family member, Form I-918A, or qualifying family member, Form I-929 [Page 4] 1.f. Special Programs Based on Certain Public Laws [] The Cuban Adjustment Act [] The Cuban Adjustment Act for battered spouses and children [] Dependent status under the Haitian Refugee Immigrant Fairness Act [] Dependent status under the Haitian Refugee Immigrant Fairness Act for battered spouses and children [] Lautenberg Parolees [] Diplomats or high ranking officials unable to return home (Section 13 of the Act of September 11, 1957) [] Indochinese Parole Adjustment Act of 2000 1.g. Additional Options [] Diversity Visa program [] Continuous residence in the United States since before January 1, 1972 ("Registry") [] Individual born in the United States under diplomatic status [] Other eligibility [Fillable field] 2. Are you applying for adjustment based on the Immigration and Nationality Act (INA) section 245(i)? Yes No NOTE: If you answered "Yes" to Item Number 2., you must have selected a family-based, employment-based, special immigrant, or Diversity Visa immigrant category listed above in Item Numbers 1.a. - 1.g. as the basis for your application for adjustment of status. Fill out the rest of this application and Supplement A to Form I-485, Adjustment of Status Under Section 245(i) (Supplement A). For detailed filing instructions, read the Form I-485 Instructions (including any Additional Instructions that relate to the immigrant category that you selected in Item Numbers 1.a. - 1.g.) and Supplement A Instructions. Information About Your Immigrant Category If you are the principal applicant, provide the following information. 3. Receipt Number of Underlying Petition (if any) 4. Priority Date from Underlying Petition (if any) (mm/dd/yyyy) If you are a derivative applicant (the spouse or unmarried child under 21 years of age of a principal applicant), provide the following information for the principal applicant. Principal Applicant's Name 5.a. Family Name (Last Name) 5.b. Given Name(First Name) 5.c. Middle Name 6. Principal Applicant's A-Number (if any) 7. Principal Applicant's Date of Birth (mm/dd/yyyy) 8. Receipt Number of Principal's Underlying Petition (if any) 9. Priority Date of Principal Applicant's Underlying Petition (if any) (mm/dd/yyyy)	[Page 5] Part 2. Application Type or Filing Category [deleted] 1. Are you filing for adjustment of status with the Executive Office for Immigration Review (EOIR) while in removal, exclusion, rescission, or deportation proceedings? Yes No 2. Receipt Number of Underlying Petition (if any) Priority Date from Underlying Petition (if any) (mm/dd/yyyy) I am filing this Form I-485 as a (select only one box): [] Principal Applicant [] Derivative Applicant (Provide the following information about the principal applicant.) Principal Applicant's Name Family Name (Last Name) Given Name (First Name) Middle Name Principal Applicant's A-Number (if any) Principal Applicant's Date of Birth (mm/dd/yyyy) I am applying based on the following category (You must select ONLY ONE category. If you are filing as a derivative applicant, select the appropriate box based on the category under which the principal applicant is applying or has applied. See the Form I-485 Instructions for more information, including any Additional Instructions that relate to the immigrant category you select.): 3.a. Family-based Immediate relative of a U.S. citizen, Form I-130, I-129F, or I-360 (select your specific category below): [] Spouse of a U.S. citizen. [] Unmarried child under 21 years of age of a U.S. citizen. [] Parent of a U.S. citizen (if the citizen is at least 21 years of age). [] Person admitted to the United States as a fiancé(e) or child of a fiancé(e) of a U.S. citizen (K-1/K-2 Nonimmigrant). [ ] Widow or widower of a U.S. citizen. [] Spouse, child, or parent of a deceased U.S. active-duty service member in the armed forces under the National Defense Authorization Act (NDAA). Other relative of a U.S. citizen under the family-based preference categories, Form I-130 (select your specific category below): [] Unmarried son or daughter of a U.S. citizen and I am 21 years of age or older. [] Married son or daughter of a U.S. citizen. [] Brother or sister of a U.S. citizen (if the citizen is at least 21 years of age). Relative of a lawful permanent resident under the family-based preference categories, Form I-130 (select your specific category below): [] Spouse of a lawful permanent resident. [] Unmarried child under 21 years of age of a lawful permanent resident. [] Unmarried son or daughter of a lawful permanent resident and I am 21 years of age or older. VAWA self-petitioner (victim of battery or extreme cruelty), Form I-360 (select your specific category below): [] VAWA self-petitioning spouse of a U.S. citizen or lawful permanent resident. [] VAWA self-petitioning child of a U.S. citizen or lawful permanent resident. [] VAWA self-petitioning parent of a U.S. citizen (if the citizen is at least 21 years of age). [Page 6] 3.b. Employment-based [] Alien Investor, Form I-526 or Form I-526E Alien Workers, Form I-140 (select your category below and answer the following questions below, as applicable): [] Alien of Extraordinary Ability [] Outstanding Professor or Researcher [] Multinational Executive or Manager [] Member of the Professions Holding an Advanced Degree or Alien of Exceptional Ability (who is NOT seeking a National Interest Waiver) [] A Professional (at a minimum, requiring a bachelor’s degree or a foreign degree equivalent to a U.S. bachelor’s degree) [] A Skilled Worker (requiring at least 2 years of specialized training or experience) [] Any Other Worker (requiring less than 2 years of training or experience) [] An Alien Applying For a National Interest Waiver (who IS a member of the professions holding an advanced degree or an alien of exceptional ability) Did a relative file the associated Form I-140 for you (or for the principal applicant if you are a derivative applicant) or does a relative have a significant ownership interest (5 percent or more) in the business that filed Form I-140 for you (or for the principal applicant, if you are a derivative applicant)? [] N/A (I am adjusting on the basis of a Form I-140 self-petition) [] No [] Yes If you answered “Yes,” is this relative your (select only one box): [] Father [] Mother [] Child [] Adult Son [] Adult Daughter [] Brother [] Sister [] None of These Is the relative above a: [] U.S. Citizen [] U.S National [] Lawful Permanent Resident [] None of These 3.c. Special Immigrant [] Special Immigrant Juvenile, Form I-360 [] Certain Afghan or Iraqi National, Form I-360 or Form DS-157 [] Certain International Broadcaster, Form I-360 [] Certain G-4 International Organization or Family Member or NATO-6 Employee or Family Member, Form I-360 [] Certain U.S. Armed Forces Members (also known as the Six and Six program), Form I-360 [] Panama Canal Zone Employees, Form I-360 [] Certain Physicians, Form I-360 [] Certain Employee or Former Employee of the U.S. Government Abroad, DS-1884 Religious Worker, Form I-360 (select your specific category below): [] Minister of Religion [] Other Religious Worker [Page 7] 3.d. Asylee or Refugee [] Asylum Status (Immigration and Nationality Act (INA) section 208), Form I-589 or Form I-730 If you selected asylum, date you were granted asylum (mm/dd/yyyy). [] Refugee Status (INA section 207), Form I-590 or Form I-730 If you selected refugee, date of initial admission as refugee (mm/dd/yyyy). 3.e. Human Trafficking Victim or Crime Victim [] Human Trafficking Victim (T Nonimmigrant), Form I-914 or Derivative Family Member, Form I-914A [] Victim of Qualifying Criminal Activity (U Nonimmigrant), Form I-918, Derivative Family Member, Form I-918A, or Qualifying Family Member, Form I-929 3.f. Special Programs Based on Certain Public Laws [] The Cuban Adjustment Act [] A Victim of Battery or Extreme Cruelty as a Spouse or Child Under the Cuban Adjustment Act [] Applicant Adjusting Based on Dependent Status Under the Haitian Refugee Immigrant Fairness Act [] A Victim of Battery or Extreme Cruelty as a Spouse or Child Applying Based on Dependent Status Under the Haitian Refugee Immigrant Fairness Act [] Lautenberg Parolees [] Diplomats or High-Ranking Officials Unable to Return Home (Section 13 of the Act of September 11, 1957) [] Nationals of Vietnam, Cambodia, and Laos Applying for Adjustment of Status Under section 586 of Public Law 106-429 [] Applicant Adjusting Under the Amerasian Act (October 22, 1982), Form I-360 3.g. Additional Options [] Diversity Visa program If you selected Diversity Visa program, provide your Diversity Visa Rank Number: [] Continuous Residence in the United States Since Before January 1, 1972 ("Registry") [] Individual Born in the United States Under Diplomatic Status [] S Nonimmigrants and Qualifying Family Members (can only adjust in this category with an approved Form I-854B filed by a law enforcement officer) [] Other Eligibility [Fillable field] [deleted] 4. If you selected a family-based, employment-based, special immigrant, or Diversity Visa immigrant category listed above in Item Numbers 3.a. - 3.g. as the basis for your application for adjustment of status, are you applying for adjustment based on INA section 245(i)? Yes No 5. Are you 21 years of age or older and applying for adjustment based on classification as a child, under the provisions of the Child Status Protection Act (CSPA)? Yes No NOTE: For more information to determine if you are eligible under CSPA, see the Who May File Form I-485 section of these Instructions. [deleted]
New		[Page 8] Part 3. Request for Exemption for Intending Immigrant’s Affidavit of Support Under Section 213A of the INA I am requesting an exemption from submitting an Affidavit of Support Under Section 213A of the INA (Form I-864 or Form I-864EZ) because (select only one): 1.a. [ ] I have earned or can receive credit for 40 qualifying quarters (credits) of work in the United States (as defined by the Social Security Act (SSA)). (Attach your SSA earnings statements. Do not count any quarters during which you received a means-tested public benefit.) 1.b. [ ] I am under 18 years of age, unmarried, the child of a U.S. citizen, am not likely to become a public charge, and will automatically become a U.S. citizen under INA section 320, upon my admission as a lawful permanent resident. 1.c. [ ] I am applying under the widow or widower of a U.S. citizen (Form I-360) immigrant category. 1.d. [ ] I am applying as a VAWA self-petitioner. 1.e. [ ] None of these exemptions apply to me and I am not required by statute to submit an Affidavit of Support Under Section 213A of the INA, nor am I required to request an exemption. 1.f. [ ] None of these exemptions apply to me and I am not requesting an exemption as I am required to submit an Affidavit of Support Under Section 213A of the INA.
Page 4-6, Part 3. Additional Information About You	[Page 4] Part 3. Additional Information About You 1. Have you ever applied for an immigrant visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad? Yes No If you answered "Yes" to Item Number 1., complete Item Numbers 2.a. - 4. below. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. Location of U.S. Embassy or U.S. Consulate 2.a. City 2.b. Country 3. Decision (for example, approved, refused, denied, withdrawn) 4. Date of Decision (mm/dd/yyyy) [Page 5] Address History Provide physical addresses for everywhere you have lived during the last five years, whether inside or outside the United States. Provide your current address first. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. Physical Address 1 (current address) 5.a. Street Number and Name 5.b. Apt./Ste./Flr. [Fillable field]5.c. City or Town 5.d. State 5.e. ZIP Code 5.f. Province 5.g. Postal Code 5.h. Country Dates of Residence 6.a. From (mm/dd/yyyy) 6.b. To (mm/dd/yyyy) Physical Address 2 7.a. Street Number and Name 7.b. Apt./Ste./Flr. [Fillable field] 7.c. City or Town 7.d. State 7.e. ZIP Code 7.f. Province 7.g. Postal Code 7.h. Country Dates of Residence 8.a. From (mm/dd/yyyy) 8.b. To (mm/dd/yyyy) Provide your most recent address outside the United States where you lived for more than one year (if not already listed above). 9.a. Street Number and Name 9.b. Apt./Ste./Flr. [Fillable field] 9.c. City or Town 9.d. State 9.e. ZIP Code 9.f. Province 9.g. Postal Code 9.h. Country Dates of Residence 10.a. From (mm/dd/yyyy) 10.b. To (mm/dd/yyyy) Employment History Provide your employment history as indicated in the instructions. Provide the most recent employment first. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. Employer 1 (current or most recent) 11. Name of Employer or Company 13. Your Occupation Address of Employer or Company 12.a. Street Number and Name 12.b. Apt./Ste./Flr. [Fillable field] 12.c. City or Town 12.d. State 12.e. ZIP Code 12.f. Province 12.g. Postal Code 12.h. Country [Page 6] Dates of Employment 14.a. From (mm/dd/yyyy) 14.b. To (mm/dd/yyyy) Employer 2 15. Name of Employer or Company Address of Employer or Company 16.a. Street Number and Name 16.b. Apt./Ste./Flr. [Fillable field] 16.c. City or Town 16.d. State 16.e. ZIP Code 16.f. Province 16.g. Postal Code 16.h. Country 17. Your Occupation Dates of Employment 18.a. From (mm/dd/yyyy) 18.b. To (mm/dd/yyyy) Provide your most recent employment outside of the United States (if not already listed above). 19. Name of Employer or Company 21. Your Occupation Address of Employer or Company 20.a. Street Number and Name 20.b. Apt./Ste./Flr. [Fillable field] 20.c. City or Town 20.d. State 20.e. ZIP Code 20.f. Province 20.g. Postal Code 20.h. Country Dates of Employment 22.a. From (mm/dd/yyyy) 22.b. To (mm/dd/yyyy)	[Page 8] Part 4. Additional Information About You 1. Have you ever applied for an immigrant visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad? Yes No If you answered “Yes,” complete Item Numbers 2. - 4. below. 2. Location of U.S. Embassy or U.S. Consulate City or Town Country 3. Decision (for example, approved, refused, denied, withdrawn) 4. Date of Decision (mm/dd/yyyy) 5. Have you previously applied for permanent residence while in the United States? Yes No 6. Have you EVER held lawful permanent resident status which was later rescinded under INA section 246? Yes No [Delete] Employment and Educational History 7. Provide ALL of your employment and educational history for the last 5 years as indicated in the Instructions. Provide your current employment or school attended first. Include periods of self-employment, unemployment, or retirement. For each period of unemployment or retirement, list source of financial support. If you have additional employment or educational history, use the space provided in Part 14. Additional Information. Employer or School (current or most recent) Name of Employer, Company, or School Your Occupation (if unemployed or retired, so state) [Page 9] Address of Employer, Company, or School Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Dates of Employment, Unemployment, Retirement, or School Attendance From (mm/dd/yyyy) To (mm/dd/yyyy) If unemployed or retired, source of financial support: [deleted] 8. Provide your most recent employer or school outside of the United States (if not already listed above). Name of Employer, Company, or School Your Occupation (if unemployed or retired, so state) Address of Employer, Company, or School Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Dates of Employment, Unemployment, Retirement, or School Attendance From (mm/dd/yyyy) To (mm/dd/yyyy) If unemployed or retired, source of financial support:
Page 6-7, Part 4. Information About Your Parents	[Page 6] Part 4. Information About Your Parents Information About Your Parent 1 Parent 1's Legal Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Parent 1's Name at Birth (if different than above) 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. Date of Birth (mm/dd/yyyy) 4. Sex Male Female 5. City or Town of Birth 6. Country of Birth [Page 7] 7. Current City or Town of Residence (if living) 8. Current Country of Residence (if living) Information About Your Parent 2 Parent 2's Legal Name 9.a. Family Name (Last Name) 9.b. Given Name (First Name) 9.c. Middle Name Parent 2's Name at Birth (if different than above) 10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name 11. Date of Birth (mm/dd/yyyy) 12. Sex Male Female 13. City or Town of Birth 14. Country of Birth 15. Current City or Town of Residence (if living) 16. Current Country of Residence (if living)	[Page 9] Part 5. Information About Your Parents Information About Your Parent 1 1. Parent 1's Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) [Page 10] 2. Parent 1's Name at Birth (if different than above) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 3. Date of Birth (mm/dd/yyyy) [deleted] [deleted] [Page 10] 4. Country of Birth [deleted] Information About Your Parent 2 5. Parent 2's Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 6. Parent 2's Name at Birth (if different than above) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 7. Date of Birth (mm/dd/yyyy) [deleted] [deleted] 8. Country of Birth [deleted]
Page 7-8, Part 5. Information About Your Marital History	[Page 7] Part 5. Information About Your Marital History 1. What is your current marital status? Single, Never Married Married Divorced Widowed Marriage Annulled Legally Separated 2. If you are married, is your spouse a current member of the U.S. armed forces or U.S. Coast Guard? N/A Yes No 3. How many times have you been married (including annulled marriages and marriages to the same person)? Information About Your Current Marriage (including if you are legally separated) If you are currently married, provide the following information about your current spouse. Current Spouse's Legal Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 5. A-Number (if any) 6. Current Spouse's Date of Birth (mm/dd/yyyy) Current Spouse's Place of Birth 8.a. City or Town 8.b. State or Province 8.c. Country Place of Marriage to Current Spouse 9.a. City or Town 9.b. State or Province 9.c. Country 7. Date of Marriage to Current Spouse (mm/dd/yyyy) 10. Is your current spouse applying with you? Yes No [Page 8] Information About Prior Marriages (if any) If you have been married before, whether in the United States or in any other country, provide the following information about your prior spouse. If you have had more than one previous marriage, use the space provided in Part 14. Additional Information to provide the information below. Prior Spouse's Legal Name (provide family name before marriage) 11.a. Family Name (Last Name) 11.b. Given Name (First Name) 11.c. Middle Name 12. Prior Spouse's Date of Birth (mm/dd/yyyy) 13. Date of Marriage to Prior Spouse (mm/dd/yyyy) Place of Marriage to Prior Spouse 14.a. City or Town 14.b. State or Province 14.c. Country Place Where Marriage with Prior Spouse Legally Ended 16.a. City or Town 16.b. State or Province 16.c. Country 15. Date Marriage with Prior Spouse Legally Ended (mm/dd/yyyy)	[Page 10] Part 6. Information About Your Marital History [no change] 3. How many times have you been married (including your current marriage, marriages abroad, annulled marriages, and marriages to the same person)? Information About Your Current Marriage (including if you are legally separated) [deleted] 4. Current Spouse's Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 5. Current Spouse's A-Number (if any) [no change] 7. Current Spouse's Country of Birth [deleted] 8. Current Spouse’s Current Physical Address Street Address City or Town State or Province Country [Page 11] 9. Place of Marriage to Current Spouse City or Town State or Province Country Date of Marriage to Current Spouse (mm/dd/yyyy) 10. Is your current spouse applying with you? Yes No Information About Prior Marriages (if any) [delete] 11. Prior Spouse's Legal Name (provide family name before marriage) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 12. Prior Spouse's Date of Birth (mm/dd/yyyy) 13. Prior Spouse’s Country of Birth 14. Prior Spouse’s Country of Citizenship or Nationality 15. Date of Marriage to Prior Spouse (mm/dd/yyyy) 16. Place of Marriage to Prior Spouse City or Town State or Province Country 17. Place Where Marriage with Prior Spouse Legally Ended City or Town State or Province Country Date Marriage with Prior Spouse Legally Ended (mm/dd/yyyy) 18. How Marriage Ended with Prior Spouse (select one): [] Annulled [] Divorced [] Spouse Deceased [] Other (Explain):
Page 8-9, Part 6. Information About Your Children	[Page 8] Part 6. Information About Your Children 1. Indicate the total number of ALL living children (including adult sons and daughters) that you have. NOTE: The term “children” includes all biological or legally adopted children, as well as current stepchildren, of any age, whether born in the United States or other countries, married or unmarried, living with you or elsewhere and includes any missing children and those born to you outside of marriage. [Fillable field] Provide the following information for each of your children. If you have more than three children, use the space provided in Part 14. Additional Information. Child 1 Current Legal Name 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. A-Number (if any) 4. Date of Birth (mm/dd/yyyy) 5. Country of Birth 6. Is this child applying with you? Yes/No Child 2 Current Legal Name 7.a. Family Name (Last Name) 7.b. Given Name (First Name) 7.c. Middle Name 8. A-Number (if any) 9. Date of Birth (mm/dd/yyyy) 10. Country of Birth 11. Is this child applying with you? Yes No [Page 9] Child 3 Current Legal Name 12.a. Family Name (Last Name) 12.b. Given Name (First Name) 12.c. Middle Name 13. A-Number (if any) 14. Date of Birth (mm/dd/yyyy) 15. Country of Birth 16. Is this child applying with you? Yes/No	[Page 12] Part 7. Information About Your Children 1. Indicate the total number of ALL living children anywhere in the world (including adult sons and daughters) that you have. [no change] Provide the following information for each of your children. If you have more than two children, use the space provided in Part 14. Additional Information. 2. Child 1 Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) A-Number (if any) Date of Birth (mm/dd/yyyy) Country of Birth What is your child’s relationship to you? (for example, biological child, stepchild, legally adopted child) Is this child also applying now on a separate Form I-485? Yes No 3. Child 2 Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) A-Number (if any) Date of Birth (mm/dd/yyyy) Country of Birth What is your child’s relationship to you? (for example, biological child, stepchild, legally adopted child) Is this child also applying now on a separate Form I-485? Yes No [deleted]
Page 9, Part 7. Biographic Information	[Page 9] Part 7. 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 13] Part 8. Biographic Information [no change] American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White [no change]
Page 9-16, Part 8. General Eligibility and Inadmissibility Grounds	[Page 9] Part 8. General Eligibility and Inadmissibility Grounds Answer Item Numbers 14. - 86.b. Choose the answer that you think is correct. If you answer “Yes” to any questions (or if you answer "No," but are unsure of your answer), provide an explanation of the events and circumstances in the space provided in Part 14. Additional Information. 1. Have you EVER been a member of, involved in, or in any way associated with any organization, association, fund, foundation, party, club, society, or similar group in the United States or in any other location in the world including any military service? Yes/No If you answered "Yes" to Item Number 1., complete Item Numbers 2. - 13.b. below. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. If you answered "No," but are unsure of your answer, provide an explanation of the events and circumstances in the space provided in Part 14. Additional Information. Organization 1 2. Name of Organization 3.a. City or Town 3.b. State or Province 3.c. Country 4. Nature of Group Dates of Membership or Dates of Involvement 5.a. From (mm/dd/yyyy) 5.b. To (mm/dd/yyyy) Organization 2 6. Name of Organization 7.a. City or Town 7.b. State or Province 7.c. Country 8. Nature of Group [Page 10] Dates of Membership or Dates of Involvement 9.a. From (mm/dd/yyyy) 9.b. To (mm/dd/yyyy) Organization 3 10. Name of Organization 11.a. City or Town 11.b. State or Province 11.c. Country 12. Nature of Group Dates of Membership or Dates of Involvement 13.a. From (mm/dd/yyyy) 13.b. To (mm/dd/yyyy) 14. Have you EVER been denied admission to the United States? Yes No 15. Have you EVER been denied a visa to the United States? Yes No 16. Have you EVER worked in the United States without authorization? Yes No 17. Have you EVER violated the terms or conditions of your nonimmigrant status? Yes No 18. Are you presently or have you EVER been in removal, exclusion, rescission, or deportation proceedings? Yes No 19. Have you EVER been issued a final order of exclusion, deportation, or removal? Yes No 20. Have you EVER had a prior final order of exclusion, deportation, or removal reinstated? Yes No 21. Have you EVER held lawful permanent resident status which was later rescinded? Yes No 22. Have you EVER been granted voluntary departure by an immigration officer or an immigration judge but failed to depart within the allotted time? Yes No 23. Have you EVER applied for any kind of relief or protection from removal, exclusion, or deportation? Yes No 24.a. Have you EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement? Yes No If you answered "Yes" to Item Number 24.a., complete Item Numbers 24.b. - 24.c. If you answered "No" to Item Number 24.a., skip to Item Number 25. 24.b. Have you complied with the foreign residence requirement? Yes No 24.c. Have you been granted a waiver or has Department of State issued a favorable waiver recommendation letter for you? Yes No Criminal Acts and Violations For Item Numbers 25. - 45., you must answer "Yes" to any question that applies to you, even if your records were sealed or otherwise cleared, or even if anyone, including a judge, law enforcement officer, or attorney, told you that you no longer have a record. You must also answer "Yes" to the following questions whether the action or offense occurred here in the United States or anywhere else in the world. If you answer "Yes" to Item Numbers 25. - 45., use the space provided in Part 14. Additional Information to provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when (date) the event occurred; and the outcome or disposition (for example, no charges filed, charges dismissed, jail, probation, community service). 25. Have you EVER been arrested, cited, charged, or detained for any reason by any law enforcement official (including but not limited to any U.S. immigration official or any official of the U.S. armed forces or U.S. Coast Guard)? Yes No 26. Have you EVER committed a crime of any kind (even if you were not arrested, cited, charged with, or tried for that crime)? Yes No [Page 11] 27. Have you EVER pled guilty to or been convicted of a crime or offense (even if the violation was subsequently expunged or sealed by a court, or if you were granted a pardon, amnesty, a rehabilitation decree, or other act of clemency)? Yes No NOTE: If you were the beneficiary of a pardon, amnesty, a rehabilitation decree, or other act of clemency, provide documentation of that post-conviction action. 28. Have you EVER been ordered punished by a judge or had conditions imposed on you that restrained your liberty (such as a prison sentence, suspended sentence, house arrest, parole, alternative sentencing, drug or alcohol treatment, rehabilitative programs or classes, probation, or community service)? Yes No 29. Have you EVER been a defendant or the accused in a criminal proceeding (including pre-trial diversion, deferred prosecution, deferred adjudication, or any withheld adjudication)? Yes No 31. Have you EVER been convicted of two or more offenses (other than purely political offenses) for which the combined sentences to confinement were five years or more? Yes No 30. Have you EVER violated (or attempted or conspired to violate) any controlled substance law or regulation of a state, the United States, or a foreign country? Yes No 32. Have you EVER illicitly (illegally) trafficked or benefited from the trafficking of any controlled substances, such as chemicals, illegal drugs, or narcotics? Yes No 33. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded in the illicit trafficking of any illegal narcotic or other controlled substances? Yes No 34. Are you the spouse, son, or daughter of a foreign national who illicitly trafficked or aided (or otherwise abetted, assisted, conspired, or colluded) in the illicit trafficking of a controlled substance, such as chemicals, illegal drugs, or narcotics and you obtained, within the last five years, any financial or other benefit from the illegal activity of your spouse or parent, although you knew or reasonably should have known that the financial or other benefit resulted from the illicit activity of your spouse or parent? Yes No 35. Have you EVER engaged in prostitution or are you coming to the United States to engage in prostitution? Yes No 36. Have you EVER directly or indirectly procured (or attempted to procure) or imported prostitutes or persons for the purpose of prostitution? Yes No 37. Have you EVER received any proceeds or money from prostitution? Yes No 38. Do you intend to engage in illegal gambling or any other form of commercialized vice, such as prostitution, bootlegging, or the sale of child pornography, while in the United States? Yes No 39. Have you EVER exercised immunity (diplomatic or otherwise) to avoid being prosecuted for a criminal offense in the United States? Yes No 40. Have you EVER, while serving as a foreign government official, been responsible for or directly carried out violations of religious freedoms? Yes No 41. Have you EVER induced by force, fraud, or coercion (or otherwise been involved in) the trafficking of persons for commercial sex acts? Yes No 42. Have you EVER trafficked a person into involuntary servitude, peonage, debt bondage, or slavery? Trafficking includes recruiting, harboring, transporting, providing, or obtaining a person for labor or services through the use of force, fraud, or coercion. Yes No 43. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with others in trafficking persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or slavery? Yes No 44. Are you the spouse, son or daughter of a foreign national who engaged in the trafficking of persons and have received or obtained, within the last five years, any financial or other benefits from the illicit activity of your spouse or your parent, although you knew or reasonably should have known that this benefit resulted from the illicit activity of your spouse or parent? Yes No 45. Have you EVER engaged in money laundering or have you EVER knowingly aided, assisted, conspired, or colluded with others in money laundering or do you seek to enter the United States to engage in such activity? Yes No [Page 12] Security and Related Do you intend to: 46.a. Engage in any activity that violates or evades any law relating to espionage (including spying) or sabotage in the United States? Yes No 46.b. Engage in any activity in the United States that violates or evades any law prohibiting the export from the United States of goods, technology, or sensitive information? Yes No 46.c. Engage in any activity whose purpose includes opposing, controlling, or overthrowing the U.S. Government by force, violence, or other unlawful means while in the United States? Yes No 46.d. Engage in any activity that could endanger the welfare, safety, or security of the United States? Yes/No 46.e. Engage in any other unlawful activity? Yes No 47. Are you engaged in or, upon your entry into the United States, do you intend to engage in any activity that could have potentially serious adverse foreign policy consequences for the United States? Yes No Have you EVER: 49. Have you EVER received any type of military, paramilitary, or weapons training? Yes No 48.a. Committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use of a weapon or explosive to harm another individual or cause substantial damage to property? Yes No 48.b. Participated in, or been a member of, a group or organization that did any of the activities described in Item Number 48.a.? Yes No 48.c. Recruited members or asked for money or things of value for a group or organization that did any of the activities described in Item Number 48.a.? Yes No 48.d. Provided money, a thing of value, services or labor, or any other assistance or support for any of the activities described in Item Number 48.a.? Yes No 48.e. Provided money, a thing of value, services or labor, or any other assistance or support for an individual, group, or organization who did any of the activities described in Item Number 48.a.? Yes No 50. Do you intend to engage in any of the activities listed in any part of Item Numbers 48.a. - 49.? Yes No NOTE: If you answered “Yes” to any part of Item Numbers 46.a. - 50., explain what you did, including the dates and location of the circumstances, or what you intend to do in the space provided in Part 14. Additional Information. Are you the spouse or child of an individual who EVER: 51.a. Committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use of a weapon or explosive to harm another individual or cause substantial damage to property? Yes/No 51.b. Participated in, or been a member or a representative of a group or organization that did any of the activities described in Item Number 51.a.? Yes/No 51.c. Recruited members, or asked for money or things of value, for a group or organization that did any of the activities described in Item Number 51.a.? Yes/No 51.d. Provided money, a thing of value, services or labor, or any other assistance or support for any of the activities described in Item Number 51.a.? Yes/No 51.e. Provided money, a thing of value, services or labor, or any other assistance or support to an individual, group, or organization who did any of the activities described in Item Number 51.a.? Yes/No 51.f. Received any type of military, paramilitary, or weapons training from a group or organization that did any of the activities described in Item Number 51.a.? Yes/No NOTE: If you answered “Yes” to any part of Item Number 51., explain the relationship and what occurred, including the dates and location of the circumstances, in the space provided in Part 14. Additional Information. 52. Have you EVER assisted or participated in selling, providing, or transporting weapons to any person who, to your knowledge, used them against another person? Yes No [Page 13] 53. Have you EVER worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Yes No 54. Have you EVER been a member of, assisted, 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 55. Have you EVER served in, been a member of, assisted, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerilla group, militia, insurgent organization, or any other armed group? Yes No 56. Have you EVER been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party (in the United States or abroad)? Yes/No 57. During the period from March 23, 1933 to May 8, 1945, did you ever order, incite, assist, or otherwise participate in the persecution of any person because of race, religion, national origin, or political opinion, in association with either the Nazi government of Germany or any organization or government associated or allied with the Nazi government of Germany? Yes No Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: 58.a. Acts involving torture or genocide? Yes No 58.b. Killing any person? Yes No 58.c. Intentionally and severely injuring any person? Yes No 58.d. Engaging in any kind of sexual contact or relations with any person who did not consent or was unable to consent, or was being forced or threatened? Yes No 58.e. Limiting or denying any person's ability to exercise religious beliefs? Yes No 59. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group? Yes No 60. Have you EVER used any person under 15 years of age to take part in hostilities, or to help or provide services to people in combat? Yes No NOTE: If you answered “Yes” to any part of Item Numbers 52. - 60., explain what occurred, including the dates and location of the circumstances, in the space provided in Part 14. Additional Information. Public Charge 61. Are you subject to the public charge ground of inadmissibility under INA section 212(a)(4)? Yes No If you answered “Yes” to Item Number 61., complete Item Numbers 62 - 68.d. below. If you answered “No” to Item Number 61., go to Item Number 69.a. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. 62. What is the size of your household? [fillable field] 63. Indicate your annual household income. [] $0-27,000 [] $27,001-52,000 [] $52,001-85,000 [] $85,001-141,000 [] Over $141,000 64. Identify the total value of your household assets. [] $0-18,400 [] $18,401-136,000 [] $136,001-321,400 [] $321,401-707,100 [] Over $707,100 [Page 14] 65. Identify the total value of your household liabilities (including both secured and unsecured liabilities). [] $0 [] $1-10,100 [] $10,101-57,700 [] $57,701-186,800 [] Over $186,800 66. What is the highest degree or level of school you have completed? [] Grades 1 through 11 [] 12th grade – no diploma [] High school diploma, GED, or alternative credential [] 1 or more years of college credit, no degree [] Associate’s degree [] Bachelor’s degree [] Master’s degree [] Professional degree (JD, MD, DMD, etc.) [] Doctorate degree 67. List your certifications, licenses, skills obtained through work experience, and educational certificates. [Fillable table][1 column x 8 rows] 68.a. Have you ever received Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), or State, Tribal, territorial, or local, cash benefit programs for income maintenance (often called “General Assistance” in the State context, but which also exist under other names)? Yes No 68.b. Have you ever received long-term institutionalization at government expense? Yes No 68.c. If your answer to Item Number 68.a. is “Yes,” list the specific benefit(s) you received, the start and end dates of each period of receipt, and the dollar amount of benefits received. [Fillable table] 68.d. If your answer to Item Number 68.b. is “Yes,” list the name, city, and state for each institution, the start and end dates of each period of institutionalization, and the reason you were institutionalized. [Fillable table] [Page 15] Illegal Entries and Other Immigration Violations 69.a. Have you EVER failed or refused to attend or to remain in attendance at any removal proceeding filed against you on or after April 1, 1997? Yes No 69.b. If your answer to Item Number 69.a. is "Yes," do you believe you had reasonable cause? Yes No 69.c. If your answer to Item Number 69.b. is "Yes," attach a written statement explaining why you had reasonable cause. 70. Have you EVER submitted fraudulent or counterfeit documentation to any U.S. Government official to obtain or attempt to obtain any immigration benefit, including a visa or entry into the United States? Yes No 71. Have you EVER lied about, concealed, or misrepresented any information on an application or petition to obtain a visa, other documentation required for entry into the United States, admission to the United States, or any other kind of immigration benefit? Yes No 72. Have you EVER falsely claimed to be a U.S. citizen (in writing or any other way)? Yes No 73. Have you EVER been a stowaway on a vessel or aircraft arriving in the United States? Yes No 74. Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or to try to enter the United States illegally (alien smuggling)? Yes No 75. Are you under a final order of civil penalty for violating INA section 274C for use of fraudulent documents? Yes No Removal, Unlawful Presence, or Illegal Reentry After Previous Immigration Violations 76. Have you EVER been excluded, deported, or removed from the United States or have you ever departed the United States on your own after having been ordered excluded, deported, or removed from the United States? Yes No 77. Have you EVER entered the United States without being inspected and admitted or paroled? Yes No Since April 1, 1997, have you been unlawfully present in the United States: 78.a. For more than 180 days but less than a year, and then departed the United States? Yes No 78.b. For one year or more and then departed the United States? Yes No NOTE: You were unlawfully present in the United States if you entered the United States without being inspected and admitted or inspected and paroled, or if you legally entered the United States but you stayed longer than permitted. Since April 1, 1997, have you EVER reentered or attempted to reenter the United States without being inspected and admitted or paroled after: 79.a. Having been unlawfully present in the United States for more than one year in the aggregate? Yes No 79.b. Having been deported, excluded, or removed from the United States? Yes No Miscellaneous Conduct 80. Do you plan to practice polygamy in the United States? Yes No 81. Are you accompanying another foreign national who requires your protection or guardianship but who is inadmissible after being certified by a medical officer as being helpless from sickness, physical or mental disability, or infancy, as described in INA section 232(c)? Yes No 82. Have you EVER assisted in detaining, retaining, or withholding custody of a U.S. citizen child outside the United States from a U.S. citizen who has been granted custody of the child? Yes No 83. Have you EVER voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or regulation in the United States? Yes No 84. Have you EVER renounced U.S. citizenship to avoid being taxed by the United States? Yes No Have you EVER: 85.a. Applied for exemption or discharge from training or service in the U.S. armed forces or in the U.S. National Security Training Corps on the ground that you are a foreign national? Yes No [Page 16] 85.b. Been relieved or discharged from such training or service on the ground that you are a foreign national? Yes No 85.c. Been convicted of desertion from the U.S. armed forces? Yes No 86.a. Have you EVER left or remained outside the United States to avoid or evade training or service in the U.S. armed forces in time of war or a period declared by the President to be a national emergency? Yes No 86.b. If your answer to Item Number 86.a. is “Yes,” what was your nationality or immigration status immediately before you left (for example, U.S. citizen or national, lawful permanent resident, nonimmigrant, parolee, present without admission or parole, or any other status)? [Fillable field]	[Page 13] Part 9. General Eligibility and Inadmissibility Grounds Choose the answer that you think is correct in Part 9. If you answer “Yes” to any questions (or if you answer “No,” but are unsure of your answer), provide an explanation of the events and circumstances in the space provided in Part 14. Additional Information. 1. Have you EVER been a member of, involved in, or in any way associated with any organization, association, fund, foundation, party, club, society, or similar group in the United States or in any other location in the world? Yes No If you answered “Yes” to Item Number 1., complete Item Numbers 2. - 9. If you were a member of more than two organizations, use the space provided in Part 14. Additional Information. Organization 1 2. Name of Organization 3. City or Town State or Province Country 4. Nature of Organization, including its purposes and activities, whether illicit or legitimate. Nature of involvement in organization, including role or position(s) held, whether illicit or legitimate. [Page 14] 5. Dates of Membership or Dates of Involvement From (mm/dd/yyyy) To (mm/dd/yyyy) Organization 2 6. Name of Organization [Page 14] 7. City or Town State or Province Country 8. Nature of Organization, including its purposes and activities, whether illicit or legitimate. Nature of involvement in organization, including role or position(s) held, whether illicit or legitimate. 9. Dates of Membership or Dates of Involvement From (mm/dd/yyyy) To (mm/dd/yyyy) [deleted] 10. Have you EVER been denied admission to the United States? Yes No 11. Have you EVER been denied a visa to the United States? Yes No 12. Have you EVER worked in the United States without employment authorization? Yes No 13. Have you EVER violated the terms or conditions of your nonimmigrant status? Yes No 14. Are you presently or have you EVER been in removal, exclusion, rescission, or deportation proceedings including expedited removal proceedings? Yes No 15. Have you EVER been issued a final order of exclusion, deportation, or removal? Yes No 16. Have you EVER had a prior final order of exclusion, deportation, or removal reinstated? Yes No [deleted] 17. Have you EVER been granted voluntary departure by an immigration officer or an immigration judge but failed to depart within the allotted time? Yes No 18. Have you EVER applied for any kind of relief or protection from removal, exclusion, or deportation? Yes No 19. Have you EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement? Yes No [deleted] 20. If you answered “Yes” to Item Number 19., have you complied with the foreign residence requirement? Yes No 21. If you answered “Yes” to Item Number 19. and “No” to Item Number 20., have you been granted a waiver or has Department of State issued a favorable waiver recommendation letter for you? Yes No Criminal Acts and Violations For Item Numbers 22. - 41., you must answer “Yes” to any question that applies to you, even if your records were sealed or otherwise cleared, or even if anyone, including a judge, law enforcement officer, or attorney, told you that you no longer have a record. You must also answer “Yes” to the following questions whether the action or offense occurred here in the United States or anywhere else in the world. If you answer “Yes” to Item Numbers 22. - 41., use the space provided in Part 14. Additional Information to provide an explanation for each offense, if applicable, that includes a description of the criminal offense; where the criminal offense occurred; when the criminal offense occurred; whether you were arrested, cited, charged, or detained for the criminal offense you committed; and the outcome or disposition of that criminal offense (for example, convicted, placement in a diversion program, no charges filed, charges dismissed, jail, prison, detention, probation, or community service). Your explanation must include the duration of any sentence to confinement (even if suspended). 22. Have you EVER been arrested, cited, charged, or permitted to participate in a diversion program (including pre-trial diversion, deferred prosecution, deferred adjudication, or any withheld adjudication), or detained for any reason by any law enforcement official in any country including but not limited to any U.S. immigration official or any official of the U.S. armed forces or U.S. Coast Guard or by a similar official of a country other than the United States? Yes No [Page 15] 23. Have you EVER committed a crime of any kind (even if you were not arrested, cited, charged with, or tried for that crime, or convicted)? Yes No 24. Have you EVER pled guilty to or been convicted of a crime or offense (even if the violation was subsequently expunged or sealed by a court, or if you were granted a pardon, amnesty, a rehabilitation decree, or other act of clemency)? Yes No NOTE: If you were the beneficiary of a pardon, amnesty, a rehabilitation decree, or other act of clemency, provide documentation of that post-conviction action. 25. Have you EVER been ordered punished by a judge or had conditions imposed on you that restrained your liberty (such as a prison sentence, suspended sentence, house arrest, parole, alternative sentencing, drug or alcohol treatment, rehabilitative programs or classes, probation, or community service)? Yes No [deleted] 26. Have you EVER violated (or attempted or conspired to violate) any controlled substance law or regulation of a state, the United States, or a foreign country? Yes No 27. Have you EVER trafficked in or benefited from, or knowingly aided, abetted, assisted, conspired or colluded in the illegal trafficking of any controlled substances, such as chemicals, illegal drugs, or narcotics? Yes No [deleted] 28. Are you the spouse, son, or daughter of a foreign national who illicitly trafficked or aided (or otherwise abetted, assisted, conspired, or colluded) in the illicit trafficking of a controlled substance, such as chemicals, illegal drugs, or narcotics and you obtained, within the last 5 years, any financial or other benefit from this activity of your spouse or parent? Yes No 29. If your answer to Item Number 28. is “Yes,” did you know or should you have reasonably known that the financial or other benefit you obtained resulted from this activity of your spouse or parent? Yes No 30. Have you EVER engaged in prostitution or are you coming to the United States to engage in prostitution? Yes No 31. Have you EVER directly or indirectly procured or attempted to procure, or imported prostitutes or persons for the purpose of prostitution? Yes No 32. Have you EVER received any proceeds or money from prostitution? Yes No 33. Do you intend to engage in illegal gambling or any other form of commercialized vice, such as prostitution, bootlegging, or the sale of child pornography, while in the United States? Yes No 34. Have you EVER exercised immunity (diplomatic or otherwise) to avoid being prosecuted for a criminal offense in the United States? Yes No 35.a. Have you EVER served as a foreign government official? Yes No 35.b. If your answer to Item Number 35.a. is “Yes,” have you EVER been responsible for, enforced, or directly carried out violations of religious freedoms? Yes No 36. Have you EVER induced by force, fraud, or coercion (or otherwise been involved in) the trafficking of another person for commercial sex acts (sex trafficking)? Yes No NOTE: Sex trafficking involves inducing or causing an adult to engage in a commercial sex act (any sex act performed for anything of value) through fraud, force, or coercion, or inducing or causing any person under 18 years of age to engage in a commercial sex act (even without force, fraud, or coercion). Sex trafficking may include recruiting, enticing, harboring, transporting, providing, obtaining, advertising, maintaining, patronizing, or soliciting by any means a person to engage in the commercial sex act knowing (or, in the case of advertising, with reckless disregard of the fact) that the person is under 18 years of age or that force, fraud, or coercion was used to induce or cause the person to engage in the commercial sex act. Sex trafficking may also include knowingly benefitting financially or by receiving anything of value, from participation in a venture involving sex trafficking. 37. Have you EVER trafficked a person into involuntary servitude, peonage, debt bondage, or slavery? Trafficking includes recruiting, harboring, transporting, providing, or obtaining a person for labor or services through the use of force, fraud, or coercion. Yes No [Page 16] 38. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with others in trafficking in persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or slavery? Yes No 39. Are you the spouse, son, or daughter of a foreign national who engaged in the trafficking in persons and have received or obtained, within the last 5 years, any financial or other benefits from this activity of your spouse or your parent? Yes No 40. If your answer is “Yes” to Item Number 39., did you know or reasonably should have known that this benefit resulted from this activity of your spouse or parent? Yes No 41. Have you EVER engaged in money laundering or have you EVER knowingly aided, assisted, abetted, conspired, or colluded with others in money laundering or do you seek to enter the United States to engage in such activity? Yes No Security and Related Do you intend to: 42.a. Engage in any activity that violates or evades any law relating to espionage (including spying) or sabotage in the United States? Yes No 42.b. Engage in any activity in the United States that violates or evades any law prohibiting the export from the United States of goods, technology, or sensitive information? Yes No 42.c. Engage in any activity whose purpose includes opposing, controlling, or overthrowing the U.S. Government by force, violence, or other unlawful means while in the United States? Yes No [deleted] 42.d. Engage in any other unlawful activity? Yes No [deleted] Have you EVER: 43.a. Received any weapons training, paramilitary training, or other military-type training? Yes No 43.b. Committed kidnapping, assassination, or hijacking or sabotage of a conveyance (including an aircraft, vessel, vehicle, or train)? Yes No 43.c. Used a weapon or explosive or any dangerous device with the intent to endanger the safety of another person or people or cause damage to property? Yes No 43.d. Threatened, attempted, conspired, prepared, or planned to do any of the things described in Item Numbers 43.b. - 43.c.? Yes No 43.e. Incited, under circumstances indicating an intention to cause death or serious bodily harm/injury, any of the activities described in Item Numbers 43.b. - 43.c.? Yes No 43.f. Participated in, or been a member of, a group or organization that did any of the activities described in Item Numbers 43.b. - 43.e.? Yes No 43.g. Recruited members or asked for money or things of value for a group or organization that did any of the activities described in Item Numbers 43.b. - 43.e.? Yes No 43.h. Provided money, a thing of value, services or labor, or any other assistance or support for any of the activities described in Item Numbers 43.b. - 43.e.? Yes No 43.i. Provided money, a thing of value, services or labor, or any other assistance or support for an individual, group, or organization who did any of the activities described in Item Numbers 43.b. - 43.e.? Yes No 44. Do you intend to engage in any of the activities listed in any part of Item Numbers 43.b. - 43.e.? Yes No 45. Do you intend to engage in any activity that could endanger the welfare, safety, or security of the United States? Yes No NOTE: If you answered “Yes” to any part of Item Numbers 42.a. - 45., explain what you did, including the dates and location of the circumstances, or what you intend to do in the space provided in Part 14. Additional Information. [Page 17] 46. Are you the spouse or child of an individual who EVER engaged in any of the activities listed in Item Numbers 43.b. - 43.i.? Yes No NOTE: If you answered “Yes” to any part of Item Number 46., explain what your parent or spouse did, including the dates and location of the circumstances in Part 14. Additional Information. [deleted] 47. Have you EVER sold, provided, or transported weapons, or assisted any person in selling, providing, or transporting weapons, which you knew or believed would be used against another person? Yes No 48. Have you EVER worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other place where people were detained, or have you EVER directed or participated in any other activity that involved detaining people? Yes No 49. Have you EVER been a member of, assisted, 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 50. Have you EVER served in, been a member of, assisted (helped), or participated in any military or police unit? Yes No 51. Have you EVER served in, been a member of, assisted (helped), or participated in any armed group (a group that carries weapons), for example: paramilitary unit (a group of people who act like a military group, but are not part of the official military), self-defense unit, vigilante unit, rebel group, or guerrilla group? Yes No If you answered “Yes” to Item Number 50. or 51., include the name of the country, the name of the military unit or armed group, your rank or position, and your dates of involvement in your explanation in Part 14. Additional Information. 52. Have you EVER been a member of, or in any way affiliated with, the Communist Party or any totalitarian party (in the United States or abroad)? Yes No [deleted] Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: 53.a. Torture? Yes No 53.b. Genocide? Yes No 53.c. Killing, or trying to kill, any person? Yes No 53.d. Intentionally and severely injuring or trying to injure any person? Yes No [deleted] 54. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to take part in hostilities or to serve in or help an armed force or group, or attempted or worked with others to do so? Yes No 55. Have you EVER used any person under 15 years of age to take part in hostilities, for instance, participating in combat or providing services related to combat (such as sabotage or serving as a courier) or providing support services (such as transporting supplies), or attempted or worked with others to do so? Yes No NOTE: If you answered “Yes” to any part of Item Numbers 47. - 55., explain what occurred, including the dates and location of the circumstances, in the space provided in Part 14. Additional Information. [Page 18] Public Charge Each noncitizen who is subject to the public charge ground of inadmissibility in INA section 212(a)(4) must complete Item Numbers 57. - 66. A noncitizen is subject to the public charge ground of inadmissibility if the noncitizen does not fall under one of the categories exempt from the public charge ground of inadmissibility listed below. If you fall under one of the exempt categories listed below, please select the exempt category, and skip Item Numbers 57. - 66. If you do not fall under one of the exempt categories listed below, select “I do not fall under any of the exempt categories listed above and will complete Item Numbers 57. - 66.” NOTE: For more information, see Part 9. General Eligibility and Inadmissibility Grounds, Public Charge section of these Instructions. 56. I am exempt from the public charge ground of inadmissibility because I am a/an (select only one box): [ ] VAWA Self-Petitioner (Form I-360) [ ] Special Immigrant Juvenile (Form I-360) [ ] Certain Afghan or Iraqi National (Form I-360 or Form DS-157) [ ] Asylee (Form I-589 or Form I-730) [ ] Refugee (Form I-590 or Form I-730) [ ] Victim of Qualifying Criminal Activity (U Nonimmigrant) under INA section 245(m) (Form I-918, Form I-918A, or Form I-929) [ ] Any category other than INA section 245(m), but you are in valid U nonimmigrant status at the time you file your application for adjustment of status. (This exemption only applies if, at the time of the adjudication of Form I-485, you are still in valid U nonimmigrant status. If, at the time of adjudication of Form I-485, you are no longer in valid U nonimmigrant status, you will be subject to the public charge ground of inadmissibility.) [ ] Human Trafficking Victim (T nonimmigrant) under INA section 245(l) (Form I-914 or Form I-914A) [ ] Any category other than INA section 245(l), but you either have a pending application for T nonimmigrant status (Form I-914) that sets forth a prima facie case for eligibility or are in valid T nonimmigrant status at the time you file your application for adjustment of status. (This exemption only applies if your Form I-914 is still pending and deemed to be prima facie eligible or you are in valid T nonimmigrant status when we adjudicate your adjustment of status application.) [ ] Cuban Adjustment Act [ ] Cuban Adjustment Act for Battered Spouses and Children [ ] Dependent Status under the Haitian Refugee Immigrant Fairness Act [ ] Dependent Status under the Haitian Refugee Immigrant Fairness Act for Battered Spouses and Children [ ] Cuban and Haitian Entrants Applying for Adjustment of Status under section 202 of the Immigration Reform and Control Act of 1986 [ ] A Lautenberg Parolee [ ] National of Vietnam, Cambodia, or Laos Applying under the Foreign Operations, Export Financing, and Related Programs Appropriations Act of 2001 [ ] Continuous Residence in the United States Since Before January 1, 1972 (“Registry”) [ ] Amerasian Homecoming Act [ ] Polish or Hungarian Parolee [ ] Nicaraguans and Other Central Americans under section 203 of the Nicaraguan Adjustment and Central American Relief Act (NACARA) [ ] American Indian Born in Canada (INA section 289) or the Texas Band of Kickapoo Indians of the Kickapoo Tribe of Oklahoma, Public Law 97-429 (Jan. 8, 1983) [ ] Section 7611 of the National Defense Authorization Act for Fiscal Year 2020 (Liberian Refugee Immigration Fairness) [Page 19] [ ] Syrian National Adjusting Status under Public Law 106-378 [ ] Spouse, Child, or Parent of a U.S. Active-Duty Service Member in the Armed Forces under the National Defense Authorization Act (NDAA) (Form I-130 or Form I-360) [ ] I do not fall under any of the exempt categories listed above and will complete Item Numbers 57. - 66. If you selected “I do not fall under any of the exempt categories listed above and will complete Item Numbers 57. - 66.” in Item Number 56., complete Item Numbers 57. - 66. below. If you selected an exempt category in Item Number 56., go to Item Number 67. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. 57. What is the size of your household? [fillable field] 58. Indicate your annual household income. [] $0-27,000 [] $27,001-52,000 [] $52,001-85,000 [] $85,001-141,000 [] Over $141,000 59. Identify the total value of your household assets. [] $0-18,400 [] $18,401-136,000 [] $136,001-321,400 [] $321,401-707,100 [] Over $707,100 60. Identify the total value of your household liabilities (including both secured and unsecured liabilities). [] $0 [] $1-10,100 [] $10,101-57,700 [] $57,701-186,800 [] Over $186,800 61. What is the highest degree or grade of school you have completed? [] Less than a high school diploma. If you select this option, indicate the highest grade of school you have completed. [fillable field] [] High school diploma, GED, or alternative credential [] 1 or more years of college credit, no degree [] Associate’s degree [] Bachelor’s degree [] Master’s degree [] Professional degree (JD, MD, DMD, etc.) [] Doctorate degree 62. List your certifications, licenses, skills obtained through work experience, and educational certificates. [Fillable table][1 column x 8 rows] 63. Have you ever received Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), or state, Tribal, territorial, or local cash benefit programs for income maintenance (often called “General Assistance” in the state context, but which also exist under other names)? Yes No 64. Have you ever received long-term institutionalization at government expense? Yes No [Page 20] 65. If your answer to Item Number 63. is “Yes,” list the specific benefit(s) you received, the start and end dates of each period of receipt, the dollar amount of benefits received, and whether you received the benefits while you were in an immigration category exempt from the public charge ground of inadmissibility. [Fillable table- Last column should have yes/no checkboxes] 66. If your answer to Item Number 64. is “Yes,” list the name, city, and state for each institution, the start and end dates of each period of institutionalization, the reason you were institutionalized, and whether you were institutionalized while you were in an immigration category exempt from the public charge ground of inadmissibility. [Fillable table- Last column should have yes/no checkboxes] Illegal Entries and Other Immigration Violations 67. Have you EVER failed or refused to attend or to remain in attendance at any removal proceeding filed against you on or after April 1, 1997? Yes No NOTE: If your answer to Item Number 67. is “Yes,” attach a written statement explaining why you failed or refused to attend or remain in attendance at the removal proceeding, including any explanation of a reasonable cause for that failure or refusal. [deleted] 68. Have you EVER submitted altered, fraudulent, or counterfeit documentation to any U.S. Government official to obtain or attempt to obtain any immigration benefit, including a visa or entry into the United States? Yes No 69. Have you EVER lied about, concealed, or misrepresented any information on an application or petition to obtain a visa, other documentation required for entry into the United States, admission to the United States, or any other immigration benefit? Yes No 70. Have you EVER falsely claimed to be a U.S. citizen (in writing or any other way)? Yes No 71. Have you EVER been a stowaway on a vessel or aircraft arriving in the United States? Yes No 72. Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or to try to enter the United States illegally (alien smuggling)? Yes No 73. Are you under a final order of civil penalty for violating INA section 274C for use of fraudulent documents? Yes No Removal, Unlawful Presence, or Illegal Reentry After Previous Immigration Violations 74. Have you EVER been excluded, deported, or removed from the United States or have you ever departed the United States on your own after having been ordered excluded, deported, or removed from the United States? Yes No 75. Have you EVER entered the United States without being inspected and admitted or paroled? Yes No [Page 21] 76. Since April 1, 1997, have you been unlawfully present in the United States? You were unlawfully present in the United States if you were present in the United States after the expiration of the period of stay authorized by the Department of Homeland Security (DHS) Secretary or were present in the United States without being admitted or paroled. Yes No NOTE: If you answered “Yes” to Item Number 76., give the dates of unlawful presence in the space provided in Part 14. Additional Information. 77. If you answered “Yes” to Item Number 76., was a severe form of trafficking in persons at least one central reason for your unlawful presence in the United States? Yes No NOTE: Severe trafficking in persons involves sex trafficking (the recruitment, harboring, transportation, provision, or obtaining of a person to commit a commercial sex act) induced by force, fraud, coercion, or in which the person is induced to perform such act has not reached 18 years of age, or the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. [deleted] Since April 1, 1997, have you EVER reentered or attempted to reenter the United States without being inspected and admitted or paroled after: 78.a. Having been unlawfully present in the United States for more than one year in the aggregate on or after April 1, 1997? You were unlawfully present in the United States for more than one year in the aggregate if you count all of the days during all of your stays that you were present in the United States after the expiration of the period of stay authorized by the DHS Secretary or were present in the United States without being admitted or paroled. Yes No 78.b. Having been deported, excluded, or removed from the United States? Yes No Miscellaneous Conduct 79. Do you plan to practice polygamy in the United States? Yes No 80. Are you accompanying an alien who is inadmissible and who has been certified by a medical officer as helpless from sickness, mental or physical disability, or infancy, and who requires your protection or guardianship, as described in INA section 232(c)? Yes No 81. Have you EVER assisted in detaining, retaining, or withholding custody of a U.S. citizen child outside the United States from a person who has been granted custody of the child? Yes No 82. Have you EVER voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or regulation in the United States? Yes No 83. Have you EVER renounced U.S. citizenship to avoid being taxed by the United States? Yes No Have you EVER: 84.a. Applied for exemption or discharge from training or service in the U.S. armed forces or in the U.S. National Security Training Corps on the ground that you are a foreign national? Yes No 84.b. Been relieved or discharged from such training or service on the ground that you are a foreign national? Yes No 84.c. Been convicted of desertion from the U.S. armed forces? Yes No 85. Have you EVER left or remained outside the United States to avoid or evade training or service in the U.S. armed forces in time of war or a period declared by the President to be a national emergency? Yes No 86. If your answered “Yes” to Item Number 85., what was your nationality or immigration status immediately before you left (for example, U.S. citizen or national, lawful permanent resident, nonimmigrant, parolee, present without admission or parole, or any other status)? [Fillable field]
Page 16, Part 9. Accommodations for Individuals With Disabilities and/or Impairments	[Page 16] Part 9. Accommodations for Individuals With Disabilities and/or Impairments NOTE: Read the information in the Form I-485 Instructions before completing this part. 1. Are you requesting an accommodation because of your disabilities and/or impairments? Yes/No If you answered "Yes" to Item Number 1., select any applicable box in Item Numbers 2.a. - 2.c. and provide an answer. 2.a. I am deaf or hard of hearing and request the following accommodation. (If you are requesting a sign-language interpreter, indicate for which language (for example, American Sign Language).): [Fillable field] 2.b. I am blind or have low vision and request the following accommodation: [Fillable field] 2.c. I have another type of disability and/or impairment. (Describe the nature of your disability and/or impairment and the accommodation you are requesting.) [Fillable field]	[deleted]
Page 16-17, Part 10. Applicant's Statement, Contact Information, Certification, and Signature	[Page 16] Part 10. Applicant's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-485 Instructions before completing this part. You must file Form I-485 while in the United States. 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. 1.b. The interpreter named in Part 11. 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. At my request, the preparer named in Part 12., [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) [Page 17] Applicant's Declaration and 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 understand that if I am a male who is 18 to 26 years of age, submitting this application will automatically register me with the Selective Service System as required by the Military Selective Service Act. 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 understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and 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.a. Applicant's Signature (sign in ink) 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.	[Page 22] Part 10. Applicant's Contact Information, Certification, and Signature [deleted] 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) Applicant's Certification and Signature [deleted] 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 11., 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. [deleted] 4. Applicant's Signature Date of Signature (mm/dd/yyyy) [deleted]
Page 17-18, Part 11. Interpreter's Contact Information, Certification, and Signature	[Page 17] Part 11. 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) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. 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) [Page 18] 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 10., 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. Interpreter's Signature 7.a. Interpreter's Signature (sign in ink) 7.b. Date of Signature (mm/dd/yyyy)	[Page 22] Part 11. Interpreter's Contact Information, Certification, and Signature [deleted] Interpreter's Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name [deleted] Interpreter's Contact Information 3. Interpreter's Daytime Telephone Number 4. Interpreter's Mobile Telephone Number (if any) 5. Interpreter's Email Address (if any) Interpreter's Certification and Signature I certify, under penalty of perjury, that I am fluent in English and [Fillable language field], 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. [deleted] 6. Interpreter's Signature Date of Signature (mm/dd/yyyy)
Page 18-19, Part 12. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 18] Part 12. 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.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./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. 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. 7.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 be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. [Page 19] 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.a. Preparer's Signature (sign in ink) 8.b. Date of Signature (mm/dd/yyyy) NOTE: Do not complete Part 13. until the USCIS Officer instructs you to do so at the interview.	[Page 23] Part 12. Contact Information, Certification, and Signature of the Person Preparing this Application, if Other Than the Applicant [deleted] Preparer's Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name [deleted] Preparer's Contact Information 3. Preparer's Daytime Telephone Number 4. Preparer's Mobile Telephone Number (if any) 5. Preparer's Email Address (if any) [deleted] Preparer's Certification and Signature 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. [deleted] 6. Preparer's Signature Date of Signature (mm/dd/yyyy) NOTE: Do not complete Part 13. until the USCIS Officer instructs you to do so at the interview.
Page 19, Part 13. Signature at Interview	[Page 19] Part 13. Signature at Interview I swear (affirm) and certify under penalty of perjury under the laws of the United States of America that I know that the contents of this Form I-485, Application to Register Permanent Residence or Adjust Status, subscribed by me, including the corrections made to this application, numbered [Blank field] through [Blank field], are complete, true, and correct. All additional pages submitted by me with this Form I-485, on numbered pages [Blank field] through [Blank field] are complete, true, and correct. All documents submitted at this interview were provided by me and are complete, true, and correct. Subscribed to and sworn to (affirmed) before me USCIS Officer's Printed Name or Stamp Date of Signature (mm/dd/yyyy) Applicant's Signature (sign in ink) USCIS Officer's Signature (sign in ink)	[Page 23] Part 13. Signature at Interview I swear (affirm) and certify under penalty of perjury under the laws of the United States of America that I know that the contents of this Form I-485, Application to Register Permanent Residence or Adjust Status, subscribed by me, including the changes made to this application, numbered [Blank field] through [Blank field], are complete, true, and correct. All information on additional pages submitted by me with this Form I-485, on numbered pages [Blank field] through [Blank field] are complete, true, and correct. All documents submitted at this interview were provided by me and are complete, true, and correct. Subscribed to and sworn to (affirmed) before me USCIS Officer's Printed Name or Stamp Date of Signature (mm/dd/yyyy) Applicant's Signature (sign in ink) USCIS Officer's Signature (sign in ink)
Page 20, Part 14. Additional Information	[Page 20] Part 14. 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.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]	[Page 24] Part 14. Additional Information [no change] 1. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) [delete] 2. Page Number Part Number Item Number [Fillable field] 3. Page Number Part Number Item Number [Fillable field] 4. Page Number Part Number Item Number [Fillable field] 5. Page Number Part Number Item Number [Fillable field]

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