Form I-485 Form I-485 Application to Register Permanent Residence or Adjust St

OMB No. 1615-0023; Expires 12/31/2010

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

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

START HERE - Type or Print (Use black ink)

For USCIS Use Only

Part 1. Information About You
Family Name (Last Name)

Receipt

Returned

Given Name (First Name)

Middle Name

Address - Street Number and Name

Apt. #

Resubmitted

C/O (in care of)
City

State

Date of Birth (mm/dd/yyyy)

Zip Code

Country of Birth

Country of Citizenship/Nationality U.S. Social Security # (if any) A # (if any)
Date of Last Arrival (mm/dd/yyyy)

I-94 #

Current USCIS Status

Expires on (mm/dd/yyyy)

Part 2. Application Type (Check one)
I am applying for an adjustment to permanent resident status because:
a.

An immigrant petition giving me an immediately available immigrant visa number
that has been approved. (Attach a copy of the approval notice, or a relative, special
immigrant juvenile, or special immigrant military visa petition filed with this
application that will give you an immediately available visa number, if approved.)

b.

My spouse or parent applied for adjustment of status or was granted lawful
permanent residence in an immigrant visa category that allows derivative status
for spouses and children.
I entered as a K-1 fiancé(e) of a U.S. citizen whom I married within 90 days of
entry, or I am the K-2 child of such a fiancé(e). (Attach a copy of the fiancé(e)
petition approval notice and the marriage certificate.)

c.

d.
e.

Reloc Sent

I was granted asylum or derivative asylum status as the spouse or child of a person
granted asylum and am eligible for adjustment.
I am a native or citizen of Cuba admitted or paroled into the United States after
January 1, 1959, and thereafter have been physically present in the United States
for at least 1 year.

f.

I am the husband, wife, or minor unmarried child of a Cuban described above in
(e), and I am residing with that person, and was admitted or paroled into the United
States after January 1, 1959, and thereafter have been physically present in the
United States for at least 1 year.

g.

I have continuously resided in the United States since before January 1, 1972.

Reloc Rec'd

Applicant
Interviewed

Section of Law
Sec. 209(a), INA
Sec. 209(b), INA
Sec. 13, Act of 9/11/57
Sec. 245, INA
Sec. 249, INA
Sec. 1 Act of 11/2/66
Sec. 2 Act of 11/2/66
Other

Country Chargeable

Eligibility Under Sec. 245
Approved Visa Petition
Dependent of Principal Alien
Special Immigrant
Other

Preference
Action Block

h.

Other basis of eligibility. Explain (for example, I was admitted as a refugee, my
status has not been terminated, and I have been physically present in the United
States for 1 year after admission). If additional space is needed, see Page 2 of the
instructions.
I am already a permanent resident and am applying to have the date I was granted
permanent residence adjusted to the date I originally arrived in the United States as
a nonimmigrant or parolee, or as of May 2, 1964, whichever date is later, and:
(Check one)
i.
I am a native or citizen of Cuba and meet the description in (e) above.

VOLAG #

j.

ATTY State License #

I am the husband, wife, or minor unmarried child of a Cuban and meet the
description in (f) above.

To be Completed by
Attorney or Representative, if any
Fill in box if Form G-28 is attached to
represent the applicant.

Form I-485 (Rev. 11/23/10) Y

Part 3. Processing Information
A. City/Town/Village of Birth

Current Occupation

Your Mother's First Name

Your Father's First Name

Give your name exactly as it appears on your Form I-94, Arrival-Departure Record
Place of Last Entry Into the United States
(City/State)

In what status did you last enter? (Visitor, student, exchange
visitor, crewman, temporary worker, without inspection, etc.)

Were you inspected by a U.S. Immigration Officer?

Yes

Nonimmigrant Visa Number
Date Visa Issued (mm/dd/yyyy)

No
Consulate Where Visa Was Issued

Gender
Male

Female

Marital Status
Married

Have you ever applied for permanent resident status in the U.S.?

Single

Divorced

Yes (If "Yes" give date and place of
filing and final disposition.)

Widowed
No

B. List your present spouse and all of your children (include adult sons and daughters). (If you have none, write "None." If additional
space is needed, see Page 2 of the instructions.)
Family Name (Last Name)

Given Name (First Name)

Country of Birth

Relationship

Family Name (Last Name)

Given Name (First Name)

Country of Birth

Relationship

Family Name (Last Name)

Given Name (First Name)

Country of Birth

Relationship

Family Name (Last Name)

Given Name (First Name)

Country of Birth

Relationship

Family Name (Last Name)

Given Name (First Name)

Country of Birth

Relationship

Middle Initial Date of Birth (mm/dd/yyyy)
A # (if any)

Applying with you?
Yes
No
Middle Initial Date of Birth (mm/dd/yyyy)

A # (if any)

Applying with you?

Yes
No
Middle Initial Date of Birth (mm/dd/yyyy)
A # (if any)

Applying with you?

Yes
No
Middle Initial Date of Birth (mm/dd/yyyy)
A # (if any)

Applying with you?

Yes
No
Middle Initial Date of Birth (mm/dd/yyyy)
A # (if any)

Applying with you?
Yes

No

Form I-485 (Rev. 11/23/10) Y Page 2

Part 3. Processing Information (Continued)
C. List your present and past membership in or affiliation with every organization, association, fund, foundation, party, club, society,
or similar group in the United States or in other places since your 16th birthday. Include any military service in this part. If none,
write "None." Include the name of each organization, location, nature, and dates of membership. If additional space is needed,
attach a separate sheet of paper. Continuation pages must be submitted according to the guidelines provided on Page 2 of the
instructions under "What Are the General Filing Instructions?"
Name of Organization

Location and Nature

Date of Membership Date of Membership
From
To

Answer the following questions. (If your answer is "Yes" to any question, explain on a separate piece of paper. Continuation pages
must be submitted according to the guidelines provided on Page 2 of the instructions under "What Are the General Filing
Instructions?" Information about documentation that must be include with your application is also provide in this section.) Answering
"Yes" does not necessarily mean that you are not entitled to adjust status or register for permanent residence.
1. Have you EVER, in or outside the United States:
a. Knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been
arrested?

Yes

No

b. Been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any law
or ordinance, excluding traffic violations?

Yes

No

c. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?

Yes

No

d. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States?

Yes

No

Yes

No

a. Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such
activities in the future?

Yes

No

b. Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?

Yes

No

c. Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States
illegally?

Yes

No

d. Illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit
trafficking of any controlled substance?

Yes

No

4. Have you EVER engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited
membership or funds for, or have you through any means ever assisted or provided any type of material
support to any person or organization that has ever engaged or conspired to engage in sabotage, kidnapping,
political assassination, hijacking, or any other form of terrorist activity?

Yes

No

2. Have you received public assistance in the United States from any source, including the U.S. Government or
any State, county, city, or municipality (other than emergency medical treatment), or are you likely to receive
public assistance in the future?
3. Have you EVER:

Form I-485 (Rev. 11/23/10) Y Page 3

Part 3. Processing Information (Continued)
5. Do you intend to engage in the United States in:
a. Espionage?

Yes

No

b. Any activity a purpose of which is opposition to, or the control or overthrow of, the Government of the
United States, by force, violence, or other unlawful means?

Yes

No

c. Any activity to violate or evade any law prohibiting the export from the United States of goods,
technology, or sensitive information?

Yes

No

6. Have you EVER been a member of, or in any way affiliated with, the Communist Party or any other
totalitarian party?

Yes

No

7. Did you, during the period from March 23, 1933, to May 8, 1945, in association with either the Nazi
Government of Germany or any organization or government associated or allied with the Nazi Government
of Germany, ever order, incite, assist, or otherwise participate in the persecution of any person because of
race, religion, national origin, or political opinion?

Yes

No

8. Have you EVER been deported from the United States, or removed from the United States at government
expense, excluded within the past year, or are you now in exclusion, deportation, removal, or rescission
proceedings?

Yes

No

9. Are you under a final order of civil penalty for violating section 274C of the Immigration and Nationality
Act for use of fraudulent documents or have you, by fraud or willful misrepresentation of a material fact,
ever sought to procure, or procured, a visa, other documentation, entry into the United States, or any
immigration benefit?

Yes

No

10. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces?

Yes

No

11. Have you EVER been a J nonimmigrant exchange visitor who was subject to the 2-year foreign residence
requirement and have not yet complied with that requirement or obtained a waiver?

Yes

No

12. Are you now withholding custody of a U.S. citizen child outside the United States from a person granted
custody of the child?

Yes

No

13. Do you plan to practice polygamy in the United States?

Yes

No

a. Acts involving torture or genocide?

Yes

No

b. Killing any person?

Yes

No

c. Intentionally and severely injuring any person?

Yes

No

d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?

Yes

No

e. Limiting or denying any person's ability to exercise religious beliefs?

Yes

No

a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, Yes
self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization?

No

b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved
detaining persons?

Yes

No

Yes

No

14. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in
any of the following:

15. Have you EVER:

16. Have you EVER been a member of, assisted in, 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?

Form I-485 (Rev. 11/23/10) Y Page 4

Part 3. Processing Information (Continued)
17. Have you EVER assisted or participated in selling or providing weapons to any person who to your
knowledge used them against another person, or in transporting weapons to any person who to your
knowledge used them against another person?

Yes

No

18. Have you EVER received any type of military, paramilitary, or weapons training?

Yes

No

Part 4. Accommodations for Individuals With Disabilities and/or Impairments (See Page 10 of the instructions
before completing this section.)
Are you requesting an accommodation because of your disability(ies) and/or impairment(s)?

Yes

No

If you answered "Yes," check any applicable box:
a. I am deaf or hard of hearing and request the following accommodation(s) (if requesting a sign-language interpreter,
indicate which language (e.g., American Sign Language)):

b. I am blind or sight-impaired and request the following accommodation(s):

c. I have another type of disability and/or impairment (describe the nature of your disability(ies) and/or impairment(s) and
accommodation(s) you are requesting):

Part 5. Signature (Read the information on penalties on Page 10 of the instructions before completing this section. You
must file this application while in the United States.)
Your Registration With U.S. Citizenship and Immigration Services
"I understand and acknowledge that, under section 262 of the Immigration and Nationality Act (INA), as an alien who has been or will
be in the United States for more than 30 days, I am required to register with U.S. Citizenship and Immigration Services (USCIS). I
understand and acknowledge that, under section 265 of the INA, I am required to provide USCIS with my current address and written
notice of any change of address within 10 days of the change. I understand and acknowledge that USCIS will use the most recent
address that I provide to USCIS, on any form containing these acknowledgements, for all purposes, including the service of a Notice
to Appear should it be necessary for USCIS to initiate removal proceedings against me. I understand and acknowledge that if I change
my address without providing written notice to USCIS, I will be held responsible for any communications sent to me at the most
recent address that I provided to USCIS. I further understand and acknowledge that, if removal proceedings are initiated against me
and I fail to attend any hearing, including an initial hearing based on service of the Notice to Appear at the most recent address that I
provided to USCIS or as otherwise provided by law, I may be ordered removed in my absence, arrested, and removed from the United
States."

Selective Service Registration
The following applies to you if you are a male at least 18 years of age, but not yet 26 years of age, who is required to register
with the Selective Service System: "I understand that my filing Form I-485 with U.S. Citizenship and Immigration Services
(USCIS) authorizes USCIS to provide certain registration information to the Selective Service System in accordance with the Military
Selective Service Act. Upon USCIS acceptance of my application, I authorize USCIS to transmit to the Selective Service System my
name, current address, Social Security Number, date of birth, and the date I filed the application for the purpose of recording my
Selective Service registration as of the filing date. If, however, USCIS does not accept my application, I further understand that, if so
required, I am responsible for registering with the Selective Service by other means, provided I have not yet reached 26 years of age."

Form I-485 (Rev. 11/23/10) Y Page 5

Part 5. Signature (Continued)
Applicant's Statement (Check one)
I can read and understand English, and I have read and understand each and every question and instruction on this form, as well
as my answer to each question.
Each and every question and instruction on this form, as well as my answer to each question, has been read to me in the
language, a language in which I am fluent, by the person named in Interpreter's Statement and
Signature. I understand each and every question and instruction on this form, as well as my answer to each question.
I certify, under penalty of perjury under the laws of the United States of America, that the information provided with this application is
all true and correct. I certify also that I have not withheld any information that would affect the outcome of this application.
I authorize the release of any information from my records that U.S. Citizenship and Immigration Services (USCIS) needs to
determine eligibility for the benefit I am seeking.
Signature (Applicant)

Date
(mm/dd/yyyy)

Print Your Full Name

Daytime Phone Number
(include area code)

NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found
eligible for the requested benefit, and this application may be denied.

Interpreter's Statement and Signature
I certify that I am fluent in English and the below-mentioned language.
Language Used (language in which applicant is fluent)

I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this
applicant in the above-mentioned language, and the applicant has understood each and every instruction and question on the form, as
well as the answer to each question.
Signature (Interpreter)

Print Your Full Name

Date
(mm/dd/yyyy)

Phone Number
(include area code)

Part 6. Signature of Person Preparing Form, If Other Than Above
I declare that I prepared this application at the request of the above applicant, and it is based on all information of which I have knowledge.

Signature

Firm Name and Address

Print Your Full Name

Date
(mm/dd/yyyy)

Phone Number
(include area code)

E-Mail Address (if any)

Form I-485 (Rev. 11/23/10) Y Page 6