table of changes – form form i-191, application for relief ... · travel document number used at...

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TABLE OF CHANGES – FORMForm I-191, Application for Relief Under Former Section 212(c) of the Immigration and

Nationality Act (INA)OMB Number: 1615-0016

09/15/2020

Reason for Revision: Comprehensive revision with standard language updates including formatting, plainlanguage, and consistency edits.Project Phase: 30 Day

Legend for Proposed Text:• Black font = Current text• Red font = Changes

Expires 02/28/2021Edition Date 12/02/2019

Current Page Numberand Section

Current Text Proposed Text

Page 1, For USCIS UseOnly

[Page 1]

For USCIS Use OnlyDateFee StampAction BlockReceivedCompletedRetd/Trans outTrans in

[Page 1]

For USCIS Use OnlyDateFee StampAction BlockReceivedCompletedRetd/Trans outTrans in

Page 1, To be completedby an attorney oraccreditedrepresentative (if any).

[Page 1]

To be completed by an attorney oraccredited representative (if any).

Select this box if Form G-28 is attached.

Attorney State Bar Number (if applicable)

Attorney or Accredited RepresentativeUSCIS Online Account Number (if any)

[Page 1]

To be completed by an Attorney orAccredited Representative.

Select this box if Form G-28 is attached.

Attorney State Bar Number

Attorney or Accredited RepresentativeUSCIS Online Account Number

Page 1-3, Part 1.Information About You

[Page 1]

START HERE- Type or print in black ink.

[Page 1]

START HERE- Type or print in black ink.Answer all questions fully and accurately. If aquestion does not apply to you (for example, ifyou have never been married and the questionasks, “Provide the name of your currentspouse”), type or print “N/A” unless otherwisedirected. If your answer to a question whichrequires a numeric response is zero or none (forexample, “How many children do you have?” or“How many times have you departed the United

AILA Doc. No. 20101600. (Posted 10/16/20)

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Part 1. Information About You

I am applying for permission to return to theUnited States under the authority contained informer section 212(c) of the Immigration andNationality Act (INA).

1. Your Full Name (do not provide a nickname)Family Name (Last Name)Given Name (First Name)Middle Name

2. Other Names UsedList all other names you have ever used,including aliases, maiden name, and nicknames.If you need extra space to complete this section,use the space provided in Part 12. AdditionalInformation.

Family Name (Last Name)Given Name (First Name)Middle Name

[Page 2]

8. Mailing AddressIn Care Of Name (if any)Street Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

9. Physical AddressStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal Code

States?”), type or print “None” unless otherwisedirected.

Part 1. Information About You

The individual applying for relief under formerImmigration and Nationality Act (INA) section212(c) completes this section.

1. Your Full Legal NameFamily Name (Last Name)Given Name (First Name)Middle Name

2. Other Names UsedProvide any other names you have used at anytime since birth, including aliases, maidennames, and nicknames. If you need extra spaceto complete this section, use the space providedin Part 12. Additional Information.

Family Name (Last Name) [x2]Given Name (First Name)[x2]Middle Name [x2]

3. Current Mailing AddressIn Care Of NameStreet Number and NameApt./Ste./Flr. NumberCity or TownStateZIP CodeProvincePostal CodeCountry

4. Is your current mailing address the same asyour physical address?YesNo

NOTE: If you answered "No" to ItemNumber 4., provide your physical addressbelow.

[Page 2]

5. Current Physical Address (if different fromthe address above)Street Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvince


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Country

[Page 1]

3. Date of Birth (mm/dd/yyyy)

4. Alien Registration Number (A-Number) (ifany)

5. USCIS Online Account Number (if any)

7. Country of Citizenship or Nationality

6. Place of Birth

City/Town/Village of BirthState/Province of BirthCountry of Birth

[Page 2]

10. Information About When and How YouBecame a Lawful Permanent Resident (LPR)

A. Date When You Obtained Your LPR Status(mm/dd/yyyy)

B. You Obtained Your LPR Status Through(select only one)Admission With an Immigrant Visa at a Port-of-EntryPort-of-Entry, If KnownMeans of TransportationAdjustment of Status While in the United StatesUSCIS Office

11. Passport Number Used at Last Entry12. Travel Document Number Used at LastEntry13. Country of Issuance for Passport or TravelDocument14. Expiration Date of This Passport or Travel

Postal CodeCountry

Other Information6. Date of Birth (mm/dd/yyyy)

7. Alien Registration Number (A-Number)

8. USCIS Online Account Number

9. Your Country of Citizenship or NationalityList the country where you are currently acitizen or national. If you need extra space tocomplete this item, use the space provided inPart 12. Additional Information.

10. Place of BirthList the city/town/village, state/ province, andcountry where you were born.City/Town/Village of BirthState/Province of BirthCountry of Birth

11. Information About Your Lawful PermanentResident (LPR) Status

A. Date You Obtained Your LPR Status(mm/dd/yyyy)

B. How You Obtained Your LPR Status (selectonly one box)Admission with an Immigrant Visa at a Port ofEntry (Complete Item Number 12.)Adjustment of Status Granted by USCIS Whilein the United States (Complete Item Number13.)Adjustment of Status Granted by ImmigrationJudge or Board of Immigration Appeals WhileInside the United States (Complete ItemNumber 14.)

12. If you selected “Admission with anImmigrant Visa at a Port of Entry,” provide theinformation requested below.Port-of-Entry City or TownPort-of-Entry StateMeans of Transportation

13. If you selected “Adjustment of StatusGranted by USCIS While in the United States,”provide the USCIS Office location that grantedyour adjustment of status application below.USCIS Office Location

14. If you selected “Adjustment of Status byImmigration Judge or Board of ImmigrationAppeals While inside the United States”


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Document (mm/dd/yyyy)

[Page 3]

15. Information About Your Departures Fromand Returns To the United States

Since being admitted as an LPR, you havedeparted from and returned to the United Statesas follows:

Departed From The United States [Table withthree columns/three rows]Place or Port-of-DepartureDate of Departure (mm/dd/yyyy)Means of TransportationReturned To The United States [Table withthree columns/three rows]Place or Port-of-EntryDate of Entry (mm/dd/yyyy)Means of Transportation

Purpose of Trips[Fillable field]

provide the date your status was granted and thelocation of the Immigration Judge below.Date Adjustment of Status was GrantedLocation of Immigration Judge

Information About Your Last Arrival in theUnited States

15. Passport or Travel Document Number

16. Country That Issued Your Passport orTravel Document17. Expiration Date for Your Passport orTravel Document (mm/dd/yyyy)

18. Date of Your Last Arrival into UnitedStates, On or About (mm/dd/yyyy)

[Page 3]

Information About Your Travels From and Tothe United States

Provide the information requested below aboutyour travels from and to the United States sinceyou were admitted as, or adjusted your status to,an LPR. If you need extra space to completethis section, use the space provided in Part 12.Additional Information.

19. Trip 1City of DepartureState of DepartureDate of Departure (mm/dd/yyyy)Means of Transportation for DepartureCity of ArrivalState of ArrivalDate of Arrival (mm/dd/yyyy)Means of Transportation for ArrivalPurpose of TripIs this information approximate?YesNo

20. Trip 2City of DepartureState of DepartureDate of Departure (mm/dd/yyyy)Means of Transportation for DepartureCity of ArrivalState of ArrivalDate of Arrival (mm/dd/yyyy)Means of Transportation for ArrivalPurpose of TripIs this information approximate?YesNo

21. Trip 3


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City of DepartureState of DepartureDate of Departure (mm/dd/yyyy)Means of Transportation for DepartureCity of ArrivalState of ArrivalDate of Arrival (mm/dd/yyyy)Means of Transportation for ArrivalPurpose of TripIs this information approximate?YesNo

Page 4, Part 2.Biographic Information

[Page 4]

Part 2. Biographic Information

1. Ethnicity (Select only one box)Hispanic or LatinoNot Hispanic or Latino

2. Race (Select all applicable boxes)WhiteAsianBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific Islander

3. HeightFeetInches

4. WeightPounds

5. Eye Color (Select only one box)BlackBlueBrownGrayGreenHazelMaroonPinkUnknown/Other

6. Hair Color (Select only one box)Bald (No hair)BlackBlondBrownGrayRedSandyWhiteUnknown/Other

[Page 4]

Part 2. Biographic Information

1. Ethnicity (Select only one box)Hispanic or LatinoNot Hispanic or Latino

2. Race (Select all applicable boxes)American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite

3. HeightFeetInches

4. WeightPounds

5. Eye Color (Select only one box)BlackBlueBrownGrayGreenHazelMaroonPinkUnknown/Other

6. Hair Color (Select only one box)Bald (No hair)BlackBlondBrownGrayRedSandyWhiteUnknown/Other

Page 4-5, Part 3.Information About YourCriminal Convictions

[Page 4]

Part 3. Information About Your CriminalConvictions

[Page 4]

Part 3. Information About Your CriminalConvictions


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The information you provide below relates tothe criminal convictions for which you areseeking relief under former section 212(c) ofthe Immigration and Nationality Act.

1. Criminal Conviction 1

A. Date (mm/dd/yyyy)

B. Name of CourtC. Location of CourtTown or CityState

D. Court Case Number

E. Conviction EnteredAfter TrialBased on Guilty or No Contest Plea

If based on guilty or no contest plea, give thedate of the guilty or no contest plea(mm/dd/yyyy)

F. Specific Offense as Stated in the ConvictionJudgment (If there is more than one offense,provide the name of each specific offense.)[Fillable field]

G. Citation to Federal, State, or Local Law, asStated in the Conviction Judgment (If there ismore than one citation, provide each separatecitation.)[Fillable field]

H. Sentence, Probation, or Other PunishmentImposed

[Page 5]





E. Conviction EnteredAfter Trial

The information requested below relates to yourcriminal convictions for which you are seekingrelief under former INA section 212(c).

1. Conviction 1


B. Name of Court[Deleted]C. City or Town of CourtState of Court



If you selected “Based on Guilty or No ContestPlea,” provide the date the plea was entered(mm/dd/yyyy).

F. Specific Offense as Stated in the Judgment ofConviction[Fillable field]

NOTE: If the conviction is related to morethan one offense, provide the name of eachspecific offense.

G. Citation to Federal, State, or Local Law, asStated in the Judgment of Conviction[Fillable field]

NOTE: If the conviction is related to morethan one citation, provide each separate citation.


Imprisonment Served From (mm/dd/yyyy)Imprisonment Served To (mm/dd/yyyy)

2. Conviction 2




E. Conviction EnteredAfter Trial


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Based on Guilty or No Contest Plea


F. Specific Offense as Stated in the ConvictionJudgment (If there is more than one offense,provide the name of each specific offense.)

G. Citation to Federal, State, or Local Law, asStated in the Conviction Judgment (If there ismore than one citation, provide each separatecitation.)








F. Specific Offense as Stated in the ConvictionJudgment (If there is more than one offense,provide the name of each specific offense.)

G. Citation to Federal, State, or Local Law, asStated in the Conviction Judgment (If there ismore than one citation, provide each separatecitation.)

Based on Guilty or No Contest Plea


[Page 5]




NOTE: If the conviction is related to morethan one citation, provide each separate citation.



3. Conviction 3









NOTE: If the conviction is related to more


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NOTE: If you were convicted more than threetimes, include the information for eachadditional conviction in Part 12. AdditionalInformation.

than one citation, provide each separate citation.



NOTE: If you have more than threeconvictions (including conviction after trial,guilty pleas, and no contest pleas), use the spaceprovided in Part 12. Additional Informationto provide the requested information about eachadditional conviction.

Page 6-7, Part 4.Information About YourResidence

[Page 6]

Part 4. Information About Your Residence

Provide the following information about whereyou have lived during the last seven years.

List your most recent residence first and thenevery other residence where you have livedduring the last seven years. There should be nogaps in time. If you need extra space tocomplete this section, use the space provided inPart 12. Additional Information.

1. Physical Address 1In Care Of Name (if any)Street Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Date of ResidenceFrom (mm/dd/yyyy)To (mm/dd/yyyy)


Date of ResidenceFrom (mm/dd/yyyy)

[Page 5]

Part 4. Information About Your Residences

Provide the following information about whereyou have lived during the last seven years. Listyour most recent residence first and then everyresidence where you have lived during the lastseven years. You should not have any gaps intime. If you need extra space to complete thissection, use the space provided in Part 12.Additional Information.

1. Physical Address 1[Deleted]Street Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal Code

Country

[Deleted]Resided From (mm/dd/yyyy)Resided To (mm/dd/yyyy)

[Page 6]

2. Physical Address 2[Deleted]Street Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

[Deleted]Resided From (mm/dd/yyyy)


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To (mm/dd/yyyy)





[Page 7]



Resided To (mm/dd/yyyy)





[Deleted]

Page 7-8, Part 5.Information About YourEmployment

[Page 7]

Part 5. Information About YourEmployment

Provide the following information about youremployment.

[Page 6]

Part 5. Information About YourEmployment

Provide the following information about whereyou have worked full-time or part-time duringthe last seven years. List your most recent


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List where you have worked full-time or part-time during the last seven years. If you needextra space to complete this section, use thespace provided in Part 12. AdditionalInformation.

1. Employer 1Name of EmployerStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

DateFrom (mm/dd/yyyy)To (mm/dd/yyyy)

Your Occupation



Your Occupation

[Page 8]


employer first and then list every otheremployer where you worked at any time duringthe last seven years. If you were unemployed,type or print “Unemployed” in the “Name ofEmployer” field and provide applicableinformation. If you need extra space tocomplete this section, use the space provided inPart 12. Additional Information.


[Deleted]Employed From (mm/dd/yyyy)Employed To (mm/dd/yyyy)

[Page 7]

Your Occupation

2. Employer 2Name of EmployerStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvince

Postal CodeCountry


Your Occupation


Postal CodeCountry


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Your Occupation


Your Occupation


Postal CodeCountry

Employed From (mm/dd/yyyy)Employed To (mm/dd/yyyy)

Your Occupation

Page 8-11, Part 6.Information About YourFamily

[Page 8]

Part 6. Information About Your Family

Provide the following information about yourfamily (for example, spouse, children, andparents). If you need extra space to completethis section, use the space provided in Part 12.Additional Information.

A. Information About Your Spouse

Spouse's Current Legal NameFamily Name (Last Name)Given Name (First Name)Middle Name

Spouse's Country of BirthSpouse's Date of Birth (mm/dd/yyyy)Spouse's Country of Citizenship or Nationality

Spouse's Physical AddressStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal Code

[Page 7]

Part 6. Information About Your Family

Provide the following information about yourspouse, all children, and your parents. If youneed extra space to complete this section, usethe space provided in Part 12. AdditionalInformation.

[Deleted]

1. Spouse's Current Legal NameFamily Name (Last Name)Given Name (First Name)Middle Name

Spouse’s Other Information2. A-Number3. USCIS Online Account Number4. Spouse’s GenderMaleFemale

5. Date of Birth (mm/dd/yyyy)

[Page 8]

6. Country of Birth7. Country of Citizenship or Nationality

8. Spouse's Physical Address[] Same as applicant’sStreet Number and NameApt./Ste./Flr.NumberCity or Town


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Country

[Page 9]

B. Information About Your Children

Provide the following information about all ofyour children.

Child 1Current Legal NameFamily Name (Last Name)Given Name (First Name)Middle Name

Country of BirthDate of Birth (mm/dd/yyyy)Country of Citizenship or Nationality

Current AddressStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry



Current AddressStreet Number and NameApt./Ste./Flr.NumberCity or TownState

StateZIP CodeProvincePostal CodeCountry

[Deleted]

9. Current Legal Name of Child 1Family Name (Last Name)Given Name (First Name)Middle Name

Other Information for Child 110. A-Number11. USCIS Online Account Number12. Child’s GenderMaleFemale

13. Date of Birth (mm/dd/yyyy)14. Country of Birth15. Country of Citizenship or Nationality

16. Physical Address of Child 1[] Same as applicant’sStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

17. Current Legal Name of Child 2




24. Physical Address of Child 2


13

ZIP CodeProvincePostal CodeCountry

[Page 10]



Current AddressStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry



Current AddressStreet Number and NameApt./Ste./Flr.NumberCity or Town

[] Same as applicant’sStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

[Page 9]





32. Physical Address of Child 3[] Same as applicant’sStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry





40. Physical Address of Child 4


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StateZIP CodeProvincePostal CodeCountry

[Page 11]

C. Information About Your Parents

Parent 1Parent 1’s Current Legal NameFamily Name (Last Name)Given Name (First Name)Middle Name

SexMaleFemale

Parent 1’s Date of Birth (mm/dd/yyyy)Parent 1’s Country of Birth

Parent 1’s Country of Citizenship or Nationality

Parent 1’s Physical AddressStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Parent 2Parent 2’s Current Legal NameFamily Name (Last Name)Given Name (First Name)Middle Name

SexMaleFemale

[] Same as applicant’sStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Information About Your Parents41. Current Legal Name of Parent 1


Other Information for Parent 142. A-Number43. USCIS Online Account Number

44. GenderMaleFemale

45. Date of Birth (mm/dd/yyyy)46. Country of Birth

[Page 10]

47. Country of Citizenship or Nationality

48. Physical Address of Parent 1[] Same as applicant’sStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

49. Current Legal Name of Parent 2


Other Information for Parent 250. A-Number51. USCIS Online Account Number

52. GenderMale


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Parent 2’s Date of Birth (mm/dd/yyyy)Parent 2’s Country of BirthParent 2’s Country of Citizenship or Nationality

Parent 2’s Physical AddressStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Female


56. Physical Address of Parent 2[] Same as applicant’sStreet Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Page 12, Part 7. OtherGrounds for Removal

[Page 12]

Part 7. Other Grounds for Removal

If you need extra space to complete yourstatement, use the space provided in Part 12.Additional Information or attach a separateletter.

If you believe you may be subject to removal onany grounds besides the criminal convictionslisted in Part 3. Information About YourCriminal Convictions, provide a fullexplanation of why you may be subject toremoval.

The other grounds of removal may be anyinadmissibility grounds in section 212(a) of theImmigration and Nationality Act or anydeportability grounds in section 237(a) of theImmigration and Nationality Act.

If you have a criminal history besides thecriminal convictions listed in Part 3.Information About Your CriminalConvictions, list these incidents and provide afull explanation. If you have ever been arrestedor detained by any law enforcement officer forany reason, and no charges were filed, includean original official statement by the arresting ordetaining agency or applicable court orderconfirming that no charges were filed.

If you were arrested or detained by any lawenforcement officer for any reason and chargeswere filed, or if charges were filed against youwithout an arrest, submit an original or court-certified copy of the complete arrest recordand/or disposition for each incident (forexample, a dismissal order or an acquittal

[Page 10]

Part 7. Other Grounds for Removal

NOTE: If you need extra space to completethis section, use the space provided in Part 12.Additional Information.

1. Provide an explanation in the space providedwhy you may be subject to removal on anygrounds besides the criminal convictions listedin Part 3. Information About Your CriminalConvictions. The other grounds of removalmay include any inadmissibility grounds in INAsection 212(a) or any deportability grounds inINA section 237(a).

[Fillable field]

[Page 11]

2. In addition to the criminal convictions listedin Part 3., list and provide a full explanation ofany other time you committed, or were accusedof committing, a criminal offense inside oroutside of the United States, as well as anyother time you were arrested, cited, detained,charged, investigated, received deferredadjudication of guilt, withholding ofadjudication of guilt, or pretrial diversion, orplead guilty to or were convicted of a criminaloffense inside or outside of the United States.

NOTE: If you were ever arrested, detained, orinvestigated by any law enforcement officer forany reason, and no charges were filed, includean original official statement by the arresting ordetaining agency or applicable court orderconfirming that no charges were filed. If you


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order).

[Fillable field]

were ever arrested, detained, or investigated byany law enforcement officer for any reason andcharges were filed, or if charges were filedagainst you without an arrest, submit an originalor court-certified copy of the complete arrestrecord and/or disposition for each incident (forexample, a dismissal order or an acquittalorder).

[Fillable field]

Page 12, Part 8.Discretion

[Page 12]

Part 8. Discretion

In the space provided below, explain why youbelieve your application should be approved asa matter of discretion, with the favorable factorsoutweighing the unfavorable factors in yourcase. For more information on discretion, seethe application Instructions. If you need extraspace to complete your statement, use the spaceprovided in Part 12. Additional Information,or attach a separate letter. Indicate in the spaceprovided if you are including a separate letter.If you submit a separate letter, you must submitthe letter at the same time as your Form I-191application.

[Fillable field]

[Page 11]

Part 8. Discretion

1. In the space provided below, explain whyU.S. Citizenship and Immigration Services(USCIS) or the immigration judge shouldapprove your Form I-191 as a matter ofdiscretion, with the favorable factorsoutweighing the unfavorable factors in yourcase. For more information on discretion, seethe Form I-191 Instructions. If you need extraspace to complete your statement, use the spaceprovided in Part 12. Additional Information.

NOTE: You may provide your explanation ona separate sheet of paper. If you use a separatesheet, select the box below and include thatsheet with your Form I-191. You must submityour explanation at the same time as your FormI-191.

[Fillable field]

2. [] I provided my explanation on a separatesheet and included that sheet with this Form I-191.

Page 13, Part 9.Applicant’s Statement,Contact Information,Certification, andSignature

[Page 13]

Part 9. Applicant’s Statement, ContactInformation, Certification, and Signature

NOTE: Read the Penalties section of the FormI-191 Instructions before completing this part.

Applicant’s Statement

NOTE: Select the box for either Item A. or B.in Item Number 1. If applicable, select the boxfor Item Number 2.

1. Applicant's Statement Regarding theInterpreter

A. I can read and understand English, and Ihave read and understand every question and

[Page 12]

Part 9. Applicant’s Statement, ContactInformation, Certification, and Signature

NOTE: Read the Penalties section of the FormI-191 Instructions before completing thissection.

Applicant’s Statement

NOTE: Select the box for either Item NumberA. or B. in Item Number 1. If applicable,select the box for Item Number 2.

1. Applicant's Statement Regarding theInterpreter

A. I can read and understand English, and Ihave read and understand every question and


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instruction on this application and my answer toevery question.

B. The interpreter named in Part 10. read to meevery question and instruction on thisapplication and my answer to every question, in[Fillable field], a language in which I am fluentand I understood everything.

2. Applicant's Statement Regarding the Preparer

At my request, the preparer named in Part 11.,[Fillable field], prepared this application for mebased only upon information I provided orauthorized.

Applicant’s Contact Information3. Applicant's Daytime Telephone Number4. Applicant's Mobile Telephone Number (ifany)5. Applicant's Email Address (if any)

Applicant’s Certification

Copies of any documents I have submitted areexact photocopies of unaltered, originaldocuments, and I understand that USCIS mayrequire that I submit original documents toUSCIS at a later date. Furthermore, I authorizethe release of any information from any of myrecords that USCIS may need to determine myeligibility for the immigration benefit I seek.

I further authorize release of informationcontained in this application, in supportingdocuments, and in my USCIS records to otherentities and persons where necessary for theadministration and enforcement of U.S.immigration laws.

I understand that USCIS may require me toappear for an appointment to take mybiometrics (fingerprints, photograph, and/orsignature) and, at that time, if I am required toprovide biometrics, I will be required to sign anoath reaffirming that:

1) I reviewed and provided or authorized all ofthe information in my application;

2) I understood all of the information containedin, and submitted with, my application; and

3) All of this information was complete, true,and correct at the time of filing.

I certify, under penalty of perjury, that Iprovided or authorized all of the information inmy application, I understand all of the

instruction on this application and my answer toevery question.

B. The interpreter named in Part 10. read to meevery question and instruction on thisapplication and my answer to every question in[Fillable Field], a language in which I amfluent, and I understood everything.

2. Applicant's Statement Regarding the Preparer

At my request, the preparer named in Part 11.,[Fillable field], prepared this application for mebased only upon information I provided orauthorized.

Applicant’s Contact Information3. Applicant’s Daytime Telephone Number4. Applicant’s Mobile Telephone Number (ifany)5. Applicant’s Email Address

Applicant’s Certification

Copies of any documents I have submitted areexact photocopies of unaltered, originaldocuments, and I understand that USCIS mayrequire that I submit original documents toUSCIS at a later date. Furthermore, I authorizethe release of any information from any and allof my records that USCIS may need todetermine my eligibility for the immigrationbenefit that I seek.

I furthermore authorize release of informationcontained in this application, in supportingdocuments, and in my USCIS records, to otherentities and persons where necessary for theadministration and enforcement of U.S.immigration law.

I understand that USCIS may require me toappear for an appointment to take mybiometrics (fingerprints, photograph, and/orsignature) and, at that time, if I am required toprovide biometrics, I will be required to sign anoath reaffirming that:

1) I reviewed and provided or authorized all ofthe information in my application;

2) I understood all of the information containedin, and submitted with, my application; and

3) All of this information was complete, true,and correct at the time of filing.

I certify, under penalty of perjury, that Iprovided or authorized all of the information inmy application, I understand all of the


18

information contained in, and submitted with,my application, and that all of this informationis complete, true, and correct.

Applicant’s Signature6. Applicant's SignatureDate of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you donot completely fill out this application or fail tosubmit required documents listed in theInstructions, USCIS (or an immigration judge ifyou are in deportation, exclusion, or removalproceedings) may deny your application.

information contained in, and submitted with,my application, and that all of this informationis complete, true, and correct.

Applicant’s Signature6. Applicant’s SignatureDate of Signature (mm/dd/yyyy)

NOTE TO ALL APPLICANTS: If you donot completely fill out this application or fail tosubmit required documents listed in theInstructions, USCIS or the immigration judgemay deny your application.

Page 14, Part 10.Interpreter’s ContactInformation,Certification, andSignature

[Page 14]

Part 10. Interpreter’s Contact Information,Certification, and Signature

Provide the following information about theinterpreter.

Interpreter’s Full Name1. Interpreter's Family Name (Last Name)Interpreter's Given Name (First Name)2. Interpreter's Business or Organization Name(if any)

Interpreter’s Mailing Address3. Street Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Interpreter’s Contact Information4. Interpreter's Daytime Telephone Number5. Interpreter's Mobile Telephone Number (ifany)6. Interpreter's Email Address (if any)

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 9.,Item B., in Item Number 1., and I have read tothis applicant in the identified language everyquestion and instruction on this application andhis or her answer to every question. The

[Page 13]

Part 10. Interpreter’s Contact Information,Certification, and Signature

If you used an interpreter (as indicated in Part 9.Item B. in Item Number 1.), you must providethe following information about the interpreter.The interpreter must sign the Interpreter’sCertification below.

Interpreter’s Full Name1. Interpreter’s Family Name (Last Name)Interpreter’s Given Name (First Name)2. Interpreter’s Business or Organization Name(if any)

Interpreter’s Mailing Address3. Street Number and NameApt./Ste./Flr. NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Interpreter’s Contact Information4. Interpreter’s Daytime Telephone Number5. Interpreter’s Mobile Telephone Number (ifany)6. Interpreter’s Email Address (if any)

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 9.,Item B., in Item Number 1., and I have read tothis applicant in the identified language everyquestion and instruction on this application andhis or her answer to every question. Theapplicant informed me that he or she


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applicant informed me that he or sheunderstands every instruction, question, andanswer on the application, including theApplicant's Certification, and has verified theaccuracy of every answer.

Interpreter’s Signature7. Interpreter's SignatureDate of Signature (mm/dd/yyyy)

understands every instruction, question, andanswer on the application, including theApplicant’s Certification, and has verified theaccuracy of every answer.

Interpreter’s Signature7. Interpreter’s SignatureDate of Signature (mm/dd/yyyy)

Page 15, Part 11.Contact Information,Declaration, andSignature of the PersonPreparing ThisApplication, if OtherThan the Applicant

[Page 15]

Part 11. Contact Information, Declaration,and Signature of the Person Preparing ThisApplication, if Other Than the Applicant

Provide the following information about thepreparer.

Preparer’s Full Name1. Preparer’s Family Name (Last Name)Preparer’s Given Name (First Name)2. Preparer’s Business or Organization Name (ifany)

Preparer’s Mailing Address3. Street Number and NameApt./Ste./Flr.NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Preparer’s Contact Information4. Preparer’s Daytime Telephone Number5. Preparer’s Mobile Telephone Number (ifany)6. Preparer’s Email Address (if any)

Preparer’s Statement

7. A. I am not an attorney or accreditedrepresentative but have prepared thisapplication on behalf of the applicant and withthe applicant's consent.

B. I am an attorney or accredited representativeand my representation of the applicant in thiscase extends/does not extend beyond thepreparation of this application.

NOTE: If you are an attorney or accreditedrepresentative, you must submit a completedForm G-28, Notice of Entry of Appearance asAttorney or Accredited Representative, withthis application.

[Page 13]

Part 11. Contact Information, Declaration,and Signature of the Person Preparing thisApplication, if Other Than the Applicant

Provide the following information about thepreparer.

Preparer’s Full Name1. Preparer’s Family Name (Last Name)Preparer’s Given Name (First Name)2. Preparer’s Business or Organization Name (ifany)

Preparer’s Mailing Address3. Street Number and NameApt./Ste./Flr. NumberCity or TownStateZIP CodeProvincePostal CodeCountry

Preparer’s Contact Information4. Preparer’s Daytime Telephone Number5. Preparer’s Mobile Telephone Number (ifany)6. Preparer’s Email Address (if any)

[Page 14]

Preparer’s Statement

7.A. I am not an attorney or accreditedrepresentative but have prepared thisapplication on behalf of the applicant and withthe applicant’s consent.

B. I am an attorney or accredited representativeand my representation of the applicant in thiscase extends/does not extend beyond thepreparation of this application.

NOTE: If you are an attorney or accreditedrepresentative, you may need to submit acompleted Form G-28, Notice of Entry ofAppearance as Attorney or AccreditedRepresentative, with this application.


20

Preparer’s CertificationBy my signature, I certify, under penalty ofperjury, that I prepared this application at therequest of the applicant. The applicant thenreviewed this completed application andinformed me that he or she understands all ofthe information contained in, and submittedwith, his or her application, including theApplicant's Certification, and that all of thisinformation is complete, true, and correct. Icompleted this application based only oninformation that the applicant provided to me orauthorized me to obtain or use.

Preparer’s Signature8. Preparer’s SignatureDate of Signature (mm/dd/yyyy)

Preparer’s CertificationBy my signature, I certify, under penalty ofperjury, that I prepared this application at therequest of the applicant. The applicant thenreviewed this completed application andinformed me that he or she understands all ofthe information contained in, and submittedwith, his or her application, including theApplicant’s Certification, and that all of thisinformation is complete, true, and correct. Icompleted this application based only oninformation that the applicant provided to me orauthorized me to obtain or use.

Preparer’s Signature8. Preparer’s SignatureDate of Signature (mm/dd/yyyy)

Page 16, Part 12.Additional Information

[Page 16]

Part 12. Additional Information

If you need extra space to provide anyadditional information within this application,use the space below. If you need more spacethan what is provided, you may make copies ofthis page to complete and file with thisapplication 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 PageNumber, Part Number, and Item Number towhich your answer refers; and sign and dateeach sheet.

1. Family Name (Last Name)Given Name (First Name)Middle Name

2. A-Number (if any)

3. A. Page NumberB. Part NumberC. Item NumberD. [Fillable field]



6. A. Page NumberB. Part NumberC. Item Number

[Page 15]

Part 12. Additional Information

If you need extra space to provide anyadditional information within this application,use the space below. If you need more spacethan what is provided, you may make copies ofthis page to complete and file with thisapplication or attach a separate sheet of paper.Type or print your name and A-Number at thetop of each sheet; indicate the Page Number,Part Number, and Item Number to whichyour answer refers; and sign and date eachsheet.

1. Family Name (Last Name) [Auto-populatedfield]Given Name (First Name) [Auto-populatedfield]Middle Name [Auto-populated field]

2. A-Number [Auto-populated field]

3.A. Page NumberB. Part NumberC. Item NumberD. [Fillable field]



6.A. Page NumberB. Part NumberC. Item Number


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D. [Fillable field] D. [Fillable field]


NOTE TO ALL APPLICANTS: Do notcomplete Part 13. USCIS will complete thissection.

Page 17, For USCIS UseOnly

[Page 17]

For USCIS Use Only

Decision

Application granted upon the following termsand conditions:[Fillable field]

Date of Action (mm/dd/yyyy)

[Page 16]

Part 13. USCIS Decision (For Official UseOnly)

[Deleted]

1. This application is:GrantedDenied

2. Terms and Conditions[Fillable field]

3. Date of Action (mm/dd/yyyy)


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