Page 1, Biographic
Information
|
[Page 1]
[new]
[new]
Family Name
First Name
Middle Name
[new]
Male Female
Date of Birth (mm/dd/yyyy)
Citizenship/Nationality
[new]
File Number
All Other Names Used (include names
by previous marriages)
[new]
City and Country of Birth
U.S. Social Security No. (if any)
Father
Family Name
First Name
Date of Birth (mm/dd/yyyy)
City, and Country of Birth (if
known)
City and Country of Residence
Mother
Family Name (Maiden Name)
First Name
Date of Birth (mm/dd/yyyy)
City, and Country of Birth (if
known)
City and Country of Residence
Current Husband or Wife (If none,
type or print “none”)
Family Name (For wife, give maiden
name)
First Name
Date of Birth (mm/dd/yyyy)
City, and Country of Birth
Date of Marriage
Place of Marriage
Former Husbands or Wives (If none,
type or print “none”)
Family Name (For wife, give maiden
name)
First Name
Date of Birth (mm/dd/yyyy)
Date and Place of Marriage
Date and Place of Termination of
Marriage
Applicant’s residence last
five years. List present address first.
[new]
[Table 5 entries]
Street Name and Number
City
Province or State
ZIP/Postal Code
Country
From Month Year
To Month Year [“Present
Time” in 1st entry]
Applicant’s last address
outside the United States of more than 1 year.
Street Name and Number
City
Province or State
ZIP/Postal Code
Country
From Month Year
To Month Year
[new]
[moved down from above]
[moved down from above]
[moved down from above]
Applicant’s employment last
five years. (If none, type or print “none.”) List
present employment first.
[Table 5 entries]
Full Name and Address of Employer
Occupation (Specify)
From Month Year
To Month Year [“Present
Time” in 1st entry]
Last occupation abroad if not
shown above. (Include all information requested above.)
|
[Page 1]
Part 1.
Information About You
1.
Full Legal Name (Do
not provide a nickname)
Family Name (Last
Name)
Given Name
(First Name)
Middle Name
(if applicable)
2. Current
Physical Address
Street Name and Number
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Date From
(mm/yyyy)
Date To
[Present]
3. Current
Mailing Address or Safe Address (if
applicable)
In Care Of
Name (if any)
Street Number
and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
4.
Date of Birth (mm/dd/yyyy)
5. Gender
Male
Female
Another Gender
Identity
[moved down]
6. USCIS
Online Account Number (if any)
7.
Alien Registration Number
(A-Number) (if any)
[deleted]
8.
All Other Names Used (include names by previous marriages)
NOTE:
Provide
all other names you have ever used, including family name at
birth, other legal names, nicknames, aliases, and assumed names.
If extra space is needed to complete this section, use the space
provided in Part
8. Additional Information.
9. City or
Town of Birth
10. Country of Birth
11. Country
of Citizenship or Nationality
[moved down to Part 4.]
[moved down]
[moved down]
[moved down]
[deleted]
[deleted]
Your
Prior Residences
12. Please
list your previous addresses for the last five years excluding
your current physical address.
[Table 4
entries]
Street
Name and Number
City
Province or State
ZIP/Postal Code
Country
From Month Year (mm/yy)
To Month Year
(mm/yy)
[deleted]
Your
Most Recent Entry into
the United States
Please provide
the following information regarding your most recent entry into
the United States.
13.a. Date
You Entered the United States, On or About (mm/dd/yyyy)
13.b.
Location at Which You Last
Entered the United States
13.c.
Immigration Status at the Time of Entry into the United States
(for example, H-2 temporary worker, H-1B temporary worker, no
status)
13.d. Date
Status Expires/Expired
(mm/dd/yyyy)
If you were
issued a Form I-94 Arrival-Departure Record Number:
14.a.
Form I-94 Arrival-Departure
Record Number
14.b.
Expiration Date of Authorized
Stay Shown on Form I-94
(mm/dd/yyyy)
Information
About Your Parent 1
15. Family Name (Last
Name)
Given Name
(First Name)
16. Date of Birth
(mm/dd/yyyy)
17. City
or Town of Birth (if known)
18.
Country of Birth (if known)
19. Current
City or Town of Residence (if living)
20. Current
Country of Residence (if living)
Information
About Your Parent 2
21. Family Name (Last
Name)
Given Name
(First Name)
22. Date of Birth
(mm/dd/yyyy)
23. City
or Town of Birth (if known)
24.
Country of Birth (if known)
25. Current
City or Town of Residence (if living)
26. Current
Country of Residence (if living)
Information
About Your Current Spouse
(If none, type or print “none”)
27. Family Name (Last
Name)
Given Name
(First Name)
28. Date of Birth
(mm/dd/yyyy)
Place of Birth
29.a. City
or Town
29.b.
Country
Place of Marriage
30.a.
City or Town
30.b. State
or Province
30.c.
Country
31. Date
of Marriage (mm/dd/yyyy)
[deleted]
|
|
[new]
|
Part 2.
Deferred Action Request
1. Please
select the request type:
[ ] Initial Request
[ ] Subsequent Request
2. Please
select the filing type for your deferred action request:
A. Labor
Investigation-Based (LIB DA)
B. Special
Immigrant Juvenile (SIJ DA)
C. Spouse,
Widow(er), Parent, Son, or Daughter of Active Duty Service Member
of U.S. Armed Forces or Individual in the Selected Reserve of the
Ready Reserve (MIL DA)
D.
Spouse, Widow(er), Parent, Son, or
Daughter of Individual (Whether Living or Deceased) who Previously
Served on Active Duty or in the Selected Reserve of the Ready
Reserve (and was not Dishonorably Discharged)
(MIL DA)
E. Medical
or Humanitarian
F. Statelessness
G. Government
Referral (Other than a Labor Agency)
H. Other
(Please review the form instructions before completing this field)
3.
Supporting Statement
In
addition to submitting evidence required to support your request
for deferred action, please provide a brief statement as to why
your request for deferred action should be considered and why you
warrant deferred action as a matter of discretion. If
extra space is needed to complete this section, use the space
provided in Part
8.
Additional Information.
[fillable
space]
|
Page 1, This form is
submitted for
|
[Page 1]
This form is submitted for:
[x] Deferred Action Request
Signature of Applicant
Date
If your native alphabet is in other
than Roman letters, write your name in your native alphabet below:
[Fillable field]
Penalties: Severe penalties are
provided by law for knowingly and willfully falsifying or
concealing a material fact.
Applicant: Print your name and
Alien Registration Number in the box outlined by heavy border
below.
Complete This box (Family Name)
(Given Name)
(Middle Name)
(Alien Registration Number)
|
[deleted]
[This content
has been modified and incorporated into current standard language
for Applicant/Interpreter/Preparer signature sections.]
[deleted]
|
|
[new]
|
Part 4.
Social Security Card
If you select
“Yes” on Part 3.
Employment Authorization,
Item Number 1., please complete
the following questions to receive a Social Security card through
this process. If the below questions and questions in Part
1. are not completed, you will
not receive a Social Security card through this process.
1.
Do you want the Social Security
Administration (SSA) to issue you an original or replacement
Social Security card?
Yes (Complete
Item Numbers 2. – 3.)
No (Go to Part
5.)
2. Provide
your Social Security Number (SSN) (if
any).
3. Consent
for Disclosure: I authorize
disclosure of information from this application and USCIS systems
to the SSA as required for the purpose of assigning me an SSN and
issuing me an original or replacement Social Security card.
Yes
No
NOTE: If
you answered “Yes” to Item
Number 1., you must also answer
“Yes” to Item Number
3., Consent for Disclosure, to
receive a card.
|
|
[new]
|
Part 5.
Requestor’s Contact Information, Certification, and
Signature
Requestor’s
Contact Information
Provide your
daytime telephone number, mobile telephone number (if any), and
email address (if any).
1.
Requestor’s Daytime Telephone Number
2.
Requestor’s Mobile Telephone Number (if any)
3.
Requestor’s Email Address (if any)
Requestor’s
Certification and Signature
I certify,
under penalty of perjury, that I provided or authorized all of the
responses and information contained in and submitted with my
request, I read and understand or, if interpreted to me in a
language in which I am fluent by the interpreter listed in Part
6., understood, all of the
responses and information contained in, and submitted with, my
request, 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.
4.
Requestor’s Signature
Date of
Signature (mm/dd/yyyy)
|
|
[new]
|
Part 6.
Interpreter’s Contact Information, Certification, and
Signature
Interpreter’s
Full Name
1.
Interpreter’s Family Name (Last Name)
Interpreter’s
Given Name (First Name)
2.
Interpreter’s Business or Organization Name (if any)
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 request and Instructions and
interpreted the requestor’s answers to the questions in that
language, and the requestor informed
me that they understood every instruction, question, and answer on
the request.
6.
Interpreter’s Signature
Date of Signature (mm/dd/yyyy)
|
|
[new]
|
Part 7.
Contact Information,
Certification, and Signature of the Person Preparing this Request,
if Other Than the Requestor
Preparer’s
Full Name
1.
Preparer’s Family Name (Last Name)
Preparer’s
Given Name (First Name)
2.
Preparer’s Business or Organization Name
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)
Preparer’s
Certification and Signature
I certify,
under penalty of perjury, that I prepared this request for the
requestor at their request and with express consent and that all
of the responses and information contained in and submitted with
the request are complete, true, and correct and reflects only
information provided by the requestor. The requestor reviewed the
responses and information and
informed me that they understand the responses and information in
or submitted with the request.
6.
Preparer’s Signature
Date of
Signature (mm/dd/yyyy)
|