Pages 13-21,
Part 9. General
Eligibility and Inadmissibility Grounds
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[Page 13]
Part 9. General Eligibility and
Inadmissibility Grounds
…
[Page
18]
Public
Charge
Each alien
who is subject to the public charge ground of inadmissibility in
INA section 212(a)(4) must complete Item Numbers 57. - 66.
An alien is subject to the public charge ground of inadmissibility
if the alien 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.”
…
[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 66. 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.
[Table, 5 columns (Benefit
Received / Start Date / End Date / Dollar Amount / In a Category
Exempt from Public Charge (Yes/No in each row for this
column)), 4 rows]
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.
[Table, 5 columns (Institution Name/City/State / Date From /
Date To / Reason / In a Category Exempt from Public Charge
(Yes/No in each row for this column)), 4 rows]
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.
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
alien 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.
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 an alien?
Yes
No
84.b. Been relieved or
discharged from such training or service on the ground that you
are an alien?
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]
|
Part 9. General Eligibility and
Inadmissibility Grounds
…
Public
Charge
Each alien
who is subject to the public charge ground of inadmissibility in
INA section 212(a)(4) must complete Item Numbers 57. - 64.
An alien is subject to the public charge ground of inadmissibility
if the alien 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. - 64.
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. -
64.”
…
[ ] 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. - 64.
If you
selected “I do not fall under any of the exempt categories
listed above and will complete Item Numbers 57. - 64.”
in Item Number 56., complete Item Numbers 57. - 64.
below. If you selected an exempt category in Item Number
56., go to Item Number 65.
If you need extra space to complete this section, use the
space provided in Part 14. Additional Information.
57.
Describe your family status (for
example, your household size). [fillable field]
[no change]
61. What
is the highest level of education
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 skills (for example, certifications,
licenses, skills obtained through work experience, and educational
certificates).
[Fillable
table][1 column x 8 rows]
63. Have
you ever received any means-tested public
benefit?
Yes
No
[deleted]
64.
If your answer to Item Number 63. is “Yes,”
list the specific means-tested public
benefit(s) you received, the start and end dates of each
period of receipt, the dollar amount
of benefits received (if applicable), and
the reason you received the benefit.
[Table, 5 columns (Means-Tested
Public Benefit Received / Start Date / End Date / Dollar
Amount (if applicable) / Reason
(Yes/No in each row for this column)), 4 rows]
[deleted]
Illegal
Entries and Other Immigration Violations
65.
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 65. 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.
66.
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
67.
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
68.
Have you EVER falsely claimed to be a U.S. citizen (in
writing or any other way)?
Yes
No
69.
Have you EVER been a stowaway on a vessel or aircraft
arriving in the United States?
Yes
No
70.
Have you EVER knowingly encouraged, induced, assisted,
abetted, or aided any alien to enter or to try to enter the United
States illegally (alien smuggling)?
Yes
No
71.
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
72.
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
73.
Have you EVER entered the United States without being
inspected and admitted or paroled?
Yes
No
74.
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 74.,
give the dates of unlawful presence in the space provided in Part
14. Additional Information.
75.
If you answered “Yes” to Item Number 74.,
was a severe form of trafficking in persons at least one central
reason for your unlawful presence in the United States?
Yes
No
[no change]
76.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
76.b.
Having been deported, excluded, or removed from the United
States?
Yes
No
Miscellaneous Conduct
77.
Do you plan to practice polygamy in the United States?
Yes
No
78.
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
79.
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
80.
Have you EVER voted in violation of any Federal, state,
or local constitutional provision, statute, ordinance, or
regulation in the United States?
Yes
No
81.
Have you EVER renounced U.S. citizenship to avoid being
taxed by the United States?
Yes
No
Have you EVER:
82.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 an alien?
Yes
No
82.b.
Been relieved or discharged from such training or service on
the ground that you are an alien?
Yes
No
82.c.
Been convicted of desertion from the U.S. armed forces?
Yes
No
83.
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
84.
If your answered “Yes” to Item Number 83.,
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]
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