Form I-643 Health and Human Services Statistical Data for Refugee/A

OMB No: 1615-0070; Expires 10/31/10

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

What Is the Purpose of This Form?
Refugees and asylees, Cuban/Haitian Entrants under the Act
of November 1, 1996, and Amerasians under Public Law
97-359 should submit Form I-643 when filing an application
for adjustment of status.
This form should be fully completed by a refugee or asylee
who is 16 years of age or older. Representatives of applicants
younger than 16 years of age should only complete Blocks 1
and 2.
Although the information requested on Form I-643 will not
affect the adjudication of the adjustment application, your
application will not be considered as completely filed unless
you submit this form. The data collected on this form will be
used by U.S. Department of Health and Human Services to
compile and analyze statistics relating to refugees and asylees.
Form I-643 will not be retained by U.S. Citizenship and
Immigration Services (USCIS).

How to Complete Form I-643
NOTE: Applicant - Print or type in blue or black ink
Section 1
Enter your name, the date on which you are completing
this form, and your Alien Registration Number on the first
line. On the second line, enter your country of birth and
your country of citizenship. On the third line, enter your
native language, your date of birth, and your telephone
number. Enter your current address on the fourth line.
Section 2
Fill in your three most recent cities and states of residence
in the United States in order, starting with your current
place of residence. If you have not lived in three different
cities since you entered the United States, write "None" on
as many lines as appropriate.
Section 3
Show the total number of people living in your household
and the number currently employed. Fill in the first line
for yourself, then list any other persons who live in your
household. If more than five persons live with you, attach
a separate page listing the others and provide the
information requested.

I-643, Health and Human Services Statistical
Data for Refugee/Asylee Adjusting Status
At the bottom of the block enter your major occupation
before coming to the United States. If you did not work
before coming to the United States, enter "None."
Section 5
Check the block or blocks that best describe your education
before coming to the United States. Also, check the block
or blocks that best describe how and where you have
learned English.
Section 6
If you have had any training or education in the United
States, check the block or blocks that best describe your
training and enter your major course of study. If you have
not had any training in the United States, enter "None."
Section 7
Check the appropriate block that best describes your ability
to speak, read, and write English.
Section 8
Check as many types of public assistance that you have
received or someone has received on your behalf. Indicate
the month and year the assistance started and stopped. If
you are still receiving assistance, write "Present" in the
block headed "To (mm/yyyy)," noting month/year.

Paperwork Reduction Act
An agency may not conduct or sponsor an information
collection and a person is not required to respond to a
collection of information unless it displays a currently valid
OMB control number. The public reporting burden for this
collection of information is estimated at 55 minutes per
response, including the time for reviewing instructions and
completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other
aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Citizenship
and Immigration Services, Regulatory Management
Division, 111 Massachusetts Avenue, N.W., 3rd Floor,
Suite 3008, Washington, DC 20529-2210. OMB No.
1615-0070. Do not mail your application to this address.

Section 4
Enter the information about all jobs you have held since
coming to the United States, starting with your current or
most recent job. Under "Job Title" write the term that best
describes the work you do, such as "machine operator,"
"nurse," or "chemist." If you have not worked at all since
coming to the United States, write "None."
Form I-643 Instructions (Rev. 10/29/09) Y

Privacy Act Notice
USCIS asks for the information on this form, and associated
evidence, to determine if you have established eligibility for
the immigration benefit for which you are filing. Our legal
right to ask for this information is in 8 U.S.C. 1302 and
1304. USCIS may provide this information to other
government agencies. Failure to provide this information,
and any requested evidence, may delay a final decision or
result in denial of your request.

Instructions to USCIS Officer
After this form has been completed, forward it directly to the
address as shown below (If you are mailing a small number
of forms, they may be folded so that the address shows
through a #10 window envelope).
Data Unit, Office of Refugee Resettlement
Department of Health and Human Services
370 L'Enfant Promenade S.W., (6th Floor)
Washington, DC 20447

Form I-643 Instructions (Rev. 10/29/09) Y Page 2

OMB No: 1615-0070; Expires 10/31/10

I-643, Health and Human Services Statistical
Data for Refugee/Asylee Adjusting Status

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

Print or type in blue or black ink.
Last (Family)
First (Given)
1. Name:
Country of Birth:

Middle

Today's Date: (mm/dd/yyyy)

Country of Citizenship/Nationality:

Native Language:

Date of Birth (mm/dd/yyyy)

Telephone Number (with area code)
(

Current Address:

)

(Number, Street, and Apartment No.)

City or Town

(Self)

Cellphone Number (with area code)
(
)

(State)

(City)

2. My three most recent cities of residence in the United States have been:

3. There are
Name

Alien Registration Number:
ASocial Security Number:

(Zip Code)

(List most recent first)

From (mm/dd/yyyy)

State

of whom are employed.
members of the household,
Relationship Gender Date of Birth Country of
Alien Number
(mm/dd/yyyy)
to Me
M/F
Birth

(Please use another sheet(s) if needed)

Currently Employed? Attending School?
Yes
No
Yes
No

(Self)

4. My employment since entering the United States has been:
(List most recent first)
Location
To
From
Company Name
City, State
(mm/dd/yyyy) (mm/dd/yyyy)

To (mm/dd/yyyy)
Present

Check One
Wage Per Part
Full
Hour Time Time

Job Title

My major occupation or profession before coming to the United States was:

5. My education before coming to the United States was:
Grades 1-8
Some high school
High school diploma
Technical school
Technical school certificate

Some university
University diploma
Graduate studies
Professional training
Graduate degree

6. I have had the following training or education in the U.S.
Type of Training/Education

(Check all that apply)

Course of Study

My knowledge of English was acquired by: (Check all that apply)
Use in another country
Training in the U.S.
Use in the U.S.

Training in refugee camp

Training in another country

Other (Please explain):

(Check all that apply)

Check If
Still Attending

High School
College
Technical/Vocational

Check If
Completed

7. English Language Skills:

(Check one)

Speaking

None
Good

A Few Words

Fair

Reading

None
Good
None

A Few Words

Fair

Writing

A Few Words
Fair
Other (specify):
Good
8. Since in the United States, list as many types of public assistance (excluding emergency medical treatment) that you have received
or someone has received on your behalf. Please include public assistance received from the U.S. Government or any State,
county, city, or municipality.
Public Assistance

From (mm/yyyy)

To (mm/yyyy)

Public Assistance

Cash assistance (Welfare)

Medical assistance

Food Stamps

Other (specify):

From (mm/yyyy)

To (mm/yyyy)

SSI
Form I-643 (Rev. 10/29/09) Y