Table of Changes (Form I-485)

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0023

12/20/2016

Reason for Revision: Comprehensive revision.

Current Section and Page Number	Current Text	Proposed Text
Page 1, To be Completed by Attorney or Representative, if any	[Page 1] Fill in box if Form G-28 is attached to represent the applicant. VOLAG No ATTY State License No.	[Page 1] Select this box if Form G-28 is attached. Volag Number (if any) Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)
Page 1, Part 1. Information About You And Page 2, Part 3. Processing Information	[Page 1] START HERE – Type or Print (Use black ink) Part 1. Information About You Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) [Page 2, Part 3.] City/Town/Village of Birth Country of Birth Country of Citizenship/Nationality A-Number (if any) U.S. Social Security No. (if any) C/O (in care of) Address – Street Number and Name Apt. No. City/State/ZIP Code [Page 2, Part 3.] Nonimmigrant Visa Number [Page 2, Part 3.] Place of Last Entry Into the United States (City/State) [Page 1, Part 1.] Date of Last Arrival (mm/dd/yyyy) [Page 2, Part 3.] In what status did you last enter? (Visitor, student, exchange visitor, crewman, temporary worker, without inspection, etc.) [Page 1, Part 1.] I-94 Number Arrival-Departure Record Number Expires on (mm/dd/yyyy) Current USCIS Status	[Page 1] START HERE – Type or print in black ink. NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, U.S. Citizenship and Immigration Services (USCIS) may deny your application. Part 1. Information About You (Person applying for lawful permanent residence) Your Current Legal Name (do not provide a nickname) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Other Names You Have Used Since Birth (if applicable) NOTE: Provide all other names you have ever used, including your family name at birth, other legal names, nicknames, aliases, and assumed names. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Information About You [subheader] 5. Date of Birth (mm/dd/yyyy) NOTE: In addition to providing your actual date of birth, include any other dates of birth you have used in connection with any legal names or non-legal names in the space provided in Part 14. Additional Information. 6. Sex M/F 7. City or Town of Birth [Page 2] 8. Country of Birth 9. Country of Citizenship or Nationality 10. Alien Registration Number (A-Number) (if any) NOTE: If you have EVER used other A-Numbers, include the additional A-Numbers in the space provided in Part 14. Additional Information. 11. USCIS Online Account Number (if any) 12. U.S. Social Security Number (if any) U.S. Mailing Address 13.a. In Care Of Name (if any) 13.b. Street Number and Name 13.c. Apt. Ste. Flr. 13.d. City or Town 13.e. State 13.f. ZIP Code Alternate and/or Safe Mailing Address If you are applying based on the Violence Against Women Act (VAWA) or as a special immigrant juvenile, human trafficking victim (T nonimmigrant), or victim of a qualifying crime (U nonimmigrant) and you do not want USCIS to send notices about this application to your home, you may provide an alternative and/or safe mailing address. 14.a. In Care Of Name (if any) 14.b. Street Number and Name 14.c. Apt. Ste. Flr. 14.d. City or Town 14.e. State 14.f. ZIP Code Recent Immigration History [subheader] Provide the information for Item Numbers 15. - 19. if you last entered the United States using a passport or travel document. 15. Passport Number Used at Last Arrival 16. Travel Document Number Used at Last Arrival 17. Expiration Date of this Passport or Travel Document (mm/dd/yyyy) 18. Country that Issued this Passport or Travel Document 19. Nonimmigrant Visa Number from this Passport (if any) Place of Last Arrival into the United States 20.a. City or Town 20.b. State 21. Date of Last Arrival (mm/dd/yyyy) When I last arrived in the United States, I: 22.a. [ ] Was inspected at a port of entry and admitted as (for example, exchange visitor; visitor, waived through; temporary worker; student): ____________ 22.b. [ ] Was inspected at a port of entry and paroled as (for example, humanitarian parole, Cuban parole) : ____________ 22.c. [ ] Came into the United States without admission or parole. 22.d. [ ] Other: ______________ If you were issued a Form I-94 Arrival-Departure Record Number: 23.a. Form I-94 Arrival-Departure Record Number __________ 23.b. Expiration Date of Authorized Stay Shown on Form I-94 (mm/dd/yyyy) ___________ 23.c. Status on Form I-94 (for example, class of admission, or paroled, if paroled) __________ [Page 3] 24. What is your current immigration status (if it has changed since your arrival)? Provide your name exactly as it appears on your Form I-94 (if any) 25.a. Family Name (Last Name) 25.b. Given Name (First Name) 25.c. Middle Name
Page 2, Part 2. Application Type	Part 2. Application Type (Check one) 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) 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. c. 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.) d. I was granted asylum or derivative asylum status as the spouse or child of a person granted asylum and am eligible for adjustment. e. 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. 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 3 of the instructions. I am applying for an adjustment to permanent resident status because: i. I am a native or citizen of Cuba and meet the description in (e) above. j. I am the husband, wife, or minor unmarried child of a Cuban and meet the description in (f) above.	[Page 3] Part 2. Application Type or Filing Category NOTE: Attach a copy of the Form I-797 receipt or approval notice for the underlying petition or application, as appropriate. I am applying to register lawful permanent residence or adjust status to that of a lawful permanent resident based on the following immigrant category (select only one box). (See the Form I-485 Instructions for more information, including any Additional Instructions that relate to the immigrant category you select.): [Delete] 1.a. Family-based [ ] Immediate relative of a U.S. citizen, Form I-130 [ ] Other relative of a U.S. citizen or relative of a lawful permanent resident under the family-based preference categories, Form I-130 [ ] Person admitted to the United States as a fiancé(e) or child of a fiancé(e) of a U.S. citizen, Form I-129F (K-1/K-2 Nonimmigrant) [ ] Widow or widower of a U.S. citizen, Form I-360 [ ] VAWA self-petitioner, Form I-360 1.b. Employment-based [ ] Alien worker, Form I-140 [ ] Alien entrepreneur, Form I-526 1.c. Special Immigrant [ ] Religious worker, Form I-360 [ ] Special immigrant juvenile, Form I-360 [ ] Certain Afghan or Iraqi national, Form I-360 [ ] Certain international broadcaster, Form I-360 [ ] Certain G-4 international organization or NATO-6 employee or family member, Form I-360 1.d. Asylee or Refugee [ ] Asylum status (INA section 208), Form I-589 or Form I-730 [Delete] [ ] Refugee status (INA section 207), Form I-590 or Form I-730 1.e. Human Trafficking Victim or Crime Victim [ ] Human trafficking victim (T Nonimmigrant), Form I-914 or derivative family member, Form I-914A [ ] Crime victim (U Nonimmigrant), Form I-918, derivative family member, Form I-918A, or qualifying family member, Form I-929 1.f. Special Programs Based on Certain Public Laws [ ] The Cuban Adjustment Act [ ] The Cuban Adjustment Act for battered spouses and children [ ] Dependent status under the Haitian Refugee Immigrant Fairness Act [ ] Dependent status under the Haitian Refugee Immigrant Fairness Act for battered spouses and children [ ] Lautenberg Parolees [ ] Diplomats or high ranking officials unable to return home (Section 13 of the Act of September 11, 1957) [ ] Indochinese Parole Adjustment Act of 2000 1.g. Additional Options [ ] Diversity Visa program [ ] Continuous residence in the United States since before January 1, 1972 (“Registry”) [ ] Individual born in the United States under diplomatic status [ ] Other eligibility _____________ [delete] 2. Are you applying for adjustment based on the Immigration and Nationality Act (INA) section 245(i)? Y/N NOTE: If you answered “Yes” to Item Number 2., you must have selected a family-based, employment-based, special immigrant, or Diversity Visa immigrant category listed above in Item Numbers 1.a. - 1.g. as the basis for your application for adjustment of status. Fill out the rest of this application and Supplement A to Form I-485, Adjustment of Status Under Section 245(i) (Supplement A). For detailed filing instructions, read the Form I-485 Instructions (including any Additional Instructions that relate to the immigrant category that you selected in Item Numbers 1.a. - 1.g.) and Supplement A Instructions. [Page 4] Information About Your Immigrant Category [subheader] If you are the principal applicant, provide the following information. 3. Receipt Number of Underlying Petition (if any) 4. Priority Date from Underlying Petition (if any) (mm/dd/yyyy) If you are a derivative applicant (the spouse or unmarried child under 21 years of age of a principal applicant), provide the following information for the principal applicant. Principal Applicant’s Name 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 6. Principal Applicant’s A-Number (if any) 7. Principal Applicant’s Date of Birth (mm/dd/yyyy) 8. Receipt Number of Principal’s Underlying Petition (if any) 9. Priority Date of Principal Applicant’s Underlying Petition (if any) (mm/dd/yyyy)
New		[Page 4] Part 3. Additional Information About You 1. Have you ever applied for an immigrant visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad? Y/N If you answered “Yes,” to Item Number 1., complete Item Numbers 2.a. - 4. below. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. Location of U.S. Embassy or U.S. Consulate 2.a. City 2.b. Country 3. Decision (for example, approved, refused, denied, withdrawn) 4. Date of Decision (mm/dd/yyyy) Address History [subheader] Provide physical addresses for everywhere you have lived during the last five years, whether inside or outside the United States. Provide your current address first. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. Physical Address 1 (current address) 5.a. Street Number and Name 5.b. Apt. Ste. Flr. 5.c. City or Town 5.d. State 5.e. ZIP Code 5.f. Province 5.g. Postal Code 5.h. Country Dates of Residence 6.a. From: __ (mm/dd/yyyy) 6.b. To: __ (mm/dd/yyyy) Physical Address 2 7.a. Street Number and Name 7.b. Apt. Ste. Flr. 7.c. City or Town 7.d. State 7.e. ZIP Code 7.f. Province 7.g. Postal Code 7.h. Country [Page 5] Dates of Residence 8.a. From: __ (mm/dd/yyyy) 8.b. To: __ (mm/dd/yyyy) Provide your most recent address outside the United States where you lived for more than one year (if not already listed above). 9.a. Street Number and Name 9.b. Apt. Ste. Flr. 9.c. City or Town 9.d. State 9.e. ZIP Code 9.f. Province 9.g. Postal Code 9.h. Country Dates of Residence 10.a. From: __ (mm/dd/yyyy) 10.b. To: __ (mm/dd/yyyy) Employment History [subheader] Provide your employment history for the last five years, whether inside or outside the United States. Provide the most recent employment first. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. Employer 1 (current or most recent) 11. Name of Employer/Company Address of Employer/Company 12.a. Street Number and Name 12.b. Apt. Ste. Flr. 12.c. City or Town 12.d. State 12.e. ZIP Code 12.f. Province 12.g. Postal Code 12.h. Country 13. Your Occupation Dates of Employment 14.a. From: __ (mm/dd/yyyy) 14.b. To: __ (mm/dd/yyyy) Employer 2 15. Name of Employer/Company Address of Employer/Company 16.a. Street Number and Name 16.b. Apt. Ste. Flr. 16.c. City or Town 16.d. State 16.e. ZIP Code 16.f. Province 16.g. Postal Code 16.h. Country 17. Your Occupation Dates of Employment 18.a. From: __ (mm/dd/yyyy) 18.b. To: __ (mm/dd/yyyy) [Page 6] Provide your most recent employment outside of the United States (if not already listed above). 19. Name of Employer/Company Address of Employer/Company 20.a. Street Number and Name 20.b. Apt. Ste. Flr. 20.c. City or Town 20.d. State 20.e. ZIP Code 20.f. Province 20.g. Postal Code 20.h. Country 21. Your Occupation Dates of Employment 22.a. From: __ (mm/dd/yyyy) 22.b. To: __ (mm/dd/yyyy)
New		[Page 6] Part 4. Information About Your Parents Information About Your Parent 1 [subheader] Parent 1’s Legal Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Parent 1’s Name at Birth (if different than above) 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. Date of Birth (mm/dd/yyyy) 4. Sex Male/Female 5. City or Town of Birth 6. Country of Birth 7. Current City or Town of Residence (if living) 8. Current Country of Residence (if living) Information About Your Parent 2 [subheader] Parent 2’s Legal Name 9.a. Family Name (Last Name) 9.b. Given Name (First Name) 9.c. Middle Name Parent 2’s Name at Birth (if different than above) 10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name 11. Date of Birth (mm/dd/yyyy) 12. Sex Male/Female 13. City or Town of Birth 14. Country of Birth 15. Current City or Town of Residence (if living) 16. Current Country of Residence (if living)
New		[Page 7] Part 5. Information About Your Marital History 1. What is your current marital status? Single, Never Married/Married/Divorced/ Widowed/Marriage Annulled/Legally Separated 2. If you are married, is your spouse a current member of the U.S. armed forces or U.S. Coast Guard? N/A / Y / N 3. How many times have you been married (including annulled marriages and marriages to the same person)? ____ Information About Your Current Marriage (including if you are legally separated) If you are currently married, provide the following information about your current spouse. Current Spouse’s Legal Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 5. A-Number (if any) ___________ 6. Current Spouse’s Date of Birth (mm/dd/yyyy) 7. Date of Marriage to Current Spouse (mm/dd/yyyy) Current Spouse’s Place of Birth 8.a. City or Town 8.b. State or Province 8.c. Country Place of Marriage to Current Spouse 9.a. City or Town 9.b. State or Province 9.c. Country 10. Is your current spouse applying with you? Information About Prior Marriages (if any) If you have been married before, whether in the United States or in any other country, provide the following information about your prior spouse. If you have had more than one previous marriage, use the space provided in Part 14. Additional Information to provide the information below. Prior Spouse’s Legal Name (provide family name before marriage) 11.a. Family Name (Last Name) 11.b. Given Name (First Name) 11.c. Middle Name 12. Prior Spouse’s Date of Birth (mm/dd/yyyy) 13. Date of Marriage to Prior Spouse (mm/dd/yyyy) Place of Marriage to Prior Spouse 14.a. City or Town 14.b. State or Province 14.c. Country 15. Date Marriage with Prior Spouse Legally Ended (mm/dd/yyyy) [Page 8] Place Where Marriage with Prior Spouse Legally Ended 16.a. City or Town 16.b. State or Province 16.c. Country
Page 3, Part 3. Processing Information	[Page 3] 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 3 of the instructions.) Family Name (Last Name)/ Given Name (First Name)/ Middle Initial A-Number (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Applying with you? Yes/No Family Name (Last Name)/ Given Name (First Name)/ Middle Initial A-Number (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Applying with you? Yes/No Family Name (Last Name)/ Given Name (First Name)/ Middle Initial A-Number (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Applying with you? Yes/No Family Name (Last Name)/ Given Name (First Name)/ Middle Initial A-Number (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Applying with you? Yes/No Family Name (Last Name)/ Given Name (First Name)/ Middle Initial A-Number (if any) Date of Birth (mm/dd/yyyy) Country of Birth Relationship Applying with you? Yes/No	[Page 8] Part 6. Information About Your Children 1. Indicate the total number of ALL living children (including adult sons and daughters) that you have. NOTE: The term “children” includes all biological or legally adopted children, as well as current stepchildren, of any age, whether born in the United States or other countries, married or unmarried, living with you or elsewhere and includes any missing children and those born to you outside of marriage._____________ Provide the following information for each of your children. If you have more than three children, use the space provided in Part 14. Additional Information. Child 1 Current Legal Name 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. A-Number (if any) 4. Date of Birth (mm/dd/yyyy) 5. Country of Birth [delete] 6. Is this child applying with you? Y/N Child 2 Current Legal Name 7.a. Family Name (Last Name) 7.b. Given Name (First Name) 7.c. Middle Name 8. A-Number (if any) 9. Date of Birth (mm/dd/yyyy) 10. Country of Birth [delete] 11. Is this child applying with you? Y/N Child 3 Current Legal Name 12.a. Family Name (Last Name) 12.b. Given Name (First Name) 12.c. Middle Name 13. A-Number (if any) 14. Date of Birth (mm/dd/yyyy) 15. Country of Birth [delete] 16. Is this child applying with you? Y/N [delete] [delete]
New		[Page 8] Part 7. Biographic Information 1. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 2. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander [Page 9] 3. Height Feet__ Inches __ 4. Weight Pounds _ ­_ _ 5. Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Pages 3-5, Part 3. Processing Information	[Page 3] Part 3. Processing Information 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 3 of the instructions under General 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? b. Been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding traffic violations? c. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? d. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the United States? 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: a. Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in the future? b. Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling? c. Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally? d. Illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit trafficking of any controlled substance? [Page 4] 10. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces? [Page 4, Part 3.] 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? [Page 4, Part 3.] 5. Do you intend to engage in the United States in: a. Espionage? c. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information? 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? [Page 3, Part 3.] 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? [Page 5, Part 3.] 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? 18. Have you EVER received any type of military, paramilitary, or weapons training? [Page 4, Part 3.] b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? [Page 4, Part 3.] 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? [Page 4, Part 3.] 15. Have you EVER: a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization? [Page 4, Part 3.] 6. Have you EVER been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party? [Page 4, Part 3.] 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? [Page 4, Part 3.] 14. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: a. Acts involving torture or genocide? b. Killing any person? c. Intentionally and severely injuring any person? d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? e. Limiting or denying any person's ability to exercise religious beliefs? [Page 4, Part 3.] 9. Are you under a final order of civil penalty for violating section 274C of the Immigration and Nationality Act (INA) 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? [Page 4, Part 3.] 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? [Page 4, Part 3.] 13. Do you plan to practice polygamy in the United States? [Page 4, Part 3] 12. Are you now withholding custody of a U.S. citizen child outside the United States from a person granted custody of the child?	[Page 9] Part 8. General Eligibility and Inadmissibility Grounds 1. Have you EVER been a member of, involved in, or in any way associated with any organization, association, fund, foundation, party, club, society, or similar group in the United States or in any other location in the world including any military service? Yes/No If you answered “Yes” to Item Number 1., complete Item Numbers 2. - 13.b. below. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. If you answered “No,” but are unsure of your answer, provide an explanation of the events and circumstances in the space provided in Part 14. Additional Information. Organization 1 2. Name of Organization 3.a. City or Town 3.b. State or Province 3.c. Country 4. Nature of the Group _________ Dates of Membership or Dates of Involvement 5.a. From __ (mm/dd/yyyy) 5.b. To __ (mm/dd/yyyy) Organization 2 6. Name of Organization 7.a. City or Town 7.b. State or Province 7.c. Country 8. Nature of the Group _________ Dates of Membership or Dates of Involvement 9.a. From __ (mm/dd/yyyy) 9.b. To __ (mm/dd/yyyy) Organization 3 10. Name of Organization 11.a. City or Town 11.b. State or Province 11.c. Country 12. Nature of the Group _________ Dates of Membership or Dates of Involvement 13.a. From __ (mm/dd/yyyy) 13.b. To __ (mm/dd/yyyy) [Page 10] Answer Item Numbers 14. - 80.b. Choose the answer that you think is correct. If you answer “Yes” to any questions (or if you answer “No,” but are unsure of your answer), provide an explanation of the events and circumstances in the space provided in Part 14. Additional Information. [delete] [delete] [delete] [delete] 14. Have you EVER been denied admission to the United States? Y/N 15. Have you EVER been denied a visa to the United States? Y/N 16. Have you EVER worked in the United States without authorization? Y/N 17. Have you EVER violated the terms or conditions of your nonimmigrant status? Y/N 18. Are you presently or have you EVER been in removal, exclusion, rescission, or deportation proceedings? Y/N 19. Have you EVER been issued a final order of exclusion, deportation, or removal? Y/N 20. Have you EVER had a prior final order of exclusion, deportation, or removal reinstated? Y/N 21. Have you EVER held lawful permanent resident status which was later rescinded? Y/N 22. Have you EVER been granted voluntary departure by an immigration officer or an immigration judge but failed to depart within the allotted time? Y/N 23. Have you EVER applied for any kind of relief or protection from removal, exclusion or deportation? Y/N 24.a. Have you EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement? Y/N If you answered “Yes” to Item Number 24.a., complete Item Numbers 24.b. - 24.c. If you answered “No” to Item Number 24.a., skip to Item Number 25. 24.b. Have you complied with the foreign residence requirement? Y/N 24.c. Have you been granted a waiver or has Department of State issued a favorable waiver recommendation letter for you? Y/N Criminal Acts and Violations For Item Numbers 25. - 45., you must answer “Yes” to any question that applies to you, even if your records were sealed or otherwise cleared, or even if anyone, including a judge, law enforcement officer or attorney, told you that you no longer have a record. You must also answer “Yes” to the following questions whether the action or offense occurred here in the United States or anywhere else in the world. If you answer “Yes” to Item Numbers 25. - 45., use the space provided in Part 14. Additional Information to provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when (date) the event occurred; and the outcome or disposition (for example, no charges filed, charges dismissed, jail, probation, community service). 25. Have you EVER been arrested, cited, charged, or detained for any reason by any law enforcement official (including but not limited to any U.S. immigration official or any official of the U.S. armed forces or U.S. Coast Guard)? Y/N 26. Have you EVER committed a crime of any kind (even if you were not arrested, cited, charged with, or tried for that crime)? Y/N 27. Have you EVER pled guilty to or been convicted of a crime or offense (even if the violation was subsequently expunged or sealed by a court, or if you were granted a pardon, amnesty, a rehabilitation decree, or other act of clemency)? Y/N NOTE: If you were the beneficiary of a pardon, amnesty, a rehabilitation decree, or other act of clemency, provide documentation of that post-conviction action. 28. Have you EVER been ordered punished by a judge or had conditions imposed on you that restrained your liberty (such as a prison sentence, suspended sentence, house arrest, parole, alternative sentencing, drug or alcohol treatment, rehabilitative programs or classes, probation, or community service)? Y/N 29. Have you EVER been a defendant or the accused in a criminal proceeding (including pre-trial diversion, deferred prosecution, deferred adjudication, or any withheld adjudication)? Y/N [Page 11] 30. Have you EVER violated (or attempted or conspired to violate) any controlled substance law or regulation of a state, the United States, or a foreign country? Y/N 31. Have you EVER been convicted of two or more offenses (other than purely political offenses) for which the combined sentences to confinement were five years or more? Y/N 32. Have you EVER illicitly (illegally) trafficked or benefited from the trafficking of any controlled substances, such as chemicals, illegal drugs, or narcotics? Y/N 33. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded in the illicit trafficking of any illegal narcotic or other controlled substances? Y/N 34. Are you the spouse, son, or daughter of a foreign national who illicitly trafficked or aided (or otherwise abetted, assisted, conspired, or colluded) in the illicit trafficking of a controlled substance, such as chemicals, illegal drugs, or narcotics and you obtained, within the last five years, any financial or other benefit from the illegal activity of your spouse or parent, although you knew or reasonably should have known that the financial or other benefit resulted from the illicit activity of your spouse or parent? Y/N 35. Have you EVER engaged in prostitution or are you coming to the United States to engage in prostitution? Y/N 36. Have you EVER directly or indirectly procured (or attempted to procure) or imported prostitutes or persons for the purpose of prostitution? Y/N 37. Have you EVER received any proceeds or money from prostitution? Y/N 38. Do you intend to engage in illegal gambling or any other form of commercialized vice, such as prostitution, bootlegging, or the sale of child pornography, while in the United States? Y/N 39. Have you EVER exercised immunity (diplomatic or otherwise) to avoid being prosecuted for a criminal offense in the United States? Y/N 40. Have you EVER, while serving as a foreign government official, been responsible for or directly carried out violations of religious freedoms? Y/N 41. Have you EVER induced by force, fraud, or coercion (or otherwise been involved in) the trafficking of persons for commercial sex acts? Y/N 42. Have you EVER trafficked a person into involuntary servitude, peonage, debt bondage, or slavery? Trafficking includes recruiting, harboring, transporting, providing, or obtaining a person for labor or services through the use of force, fraud, or coercion. Y/N 43. Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with others in trafficking persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or slavery? Y/N 44. Are you the spouse, son or daughter of a foreign national who engaged in the trafficking of persons and have received or obtained, within the last five years, any financial or other benefits from the illicit activity of your spouse or your parent, although you knew or reasonably should have known that this benefit resulted from the illicit activity of your spouse or parent? Y/N 45. Have you EVER engaged in money laundering or have you EVER knowingly aided, assisted, conspired, or colluded with others in money laundering or do you seek to enter the United States to engage in such activity? Y/N Security and Related Do you intend to: 46.a. Engage in any activity that violates or evades any law relating to espionage (including spying) or sabotage in the United States? Y/N 46.b. Engage in any activity in the United States that violates or evades any law prohibiting the export from the United States of goods, technology, or sensitive information? Y/N 46.c. Engage in any activity whose purpose includes opposing, controlling, or overthrowing the U.S. Government by force, violence, or other unlawful means while in the United States? Y/N 46.d. Engage in any activity that could endanger the welfare, safety, or security of the United States? Y/N [Page 12] 46.e. Engage in any other unlawful activity? Y/N 47. Are you engaged in or, upon your entry into the United States, do you intend to engage in any activity that could have potentially serious adverse foreign policy consequences for the United States? Y/N Have you EVER: 48.a. Committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use of a weapon or explosive to harm another individual or cause substantial damage to property? Y/N 48.b. Participated in, or been a member of, a group or organization that did any of the activities described in Item Number 48.a.? Y/N 48.c. Recruited members or asked for money or things of value for a group or organization that did any of the activities described in Item Number 48.a.? Y/N 48.d. Provided money, a thing of value, services or labor, or any other assistance or support for any of the activities described in Item Number 48.a.? Y/N 48.e. Provided money, a thing of value, services or labor, or any other assistance or support for an individual, group, or organization who did any of the activities described in Item Number 48.a.? Y/N 49. Have you EVER received any type of military, paramilitary, or weapons training? Y/N 50. Do you intend to engage in any of the activities listed in any part of Item Numbers 48. - 49.? Y/N NOTE: If you answered “Yes” to any part of Item Numbers 46.a. - 50., explain what you did, including the dates and location of the circumstances, or what you intend to do in the space provided in Part 14. Additional Information. Are you the spouse or child of an individual who EVER: 51.a. Committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use of a weapon or explosive to harm another individual or cause substantial damage to property? Y/N 51.b. Participated in, or been a member or a representative of a group or organization that did any of the activities described in Item Number 51.a.? Y/N 51.c. Recruited members, or asked for money or things of value, for a group or organization that did any of the activities described in Item Number 51.a.? Y/N 51.d. Provided money, a thing of value, services or labor, or any other assistance or support for any of the activities described in Item Number 51.a.? Y/N 51.e. Provided money, a thing of value, services or labor, or any other assistance or support to an individual, group, or organization who did any of the activities described in Item Number 51.a.? Y/N 51.f. Received any type of military, paramilitary, or weapons training from a group or organization that did any of the activities described in Item Number 51.a.? Y/N NOTE: If you answered “Yes” to any part of Item Number 51., explain the relationship and what occurred, including the dates and location of the circumstances, in the space provided in Part 14. Additional Information. 52. Have you EVER assisted or participated in selling, providing, or transporting weapons to any person who, to your knowledge, used them against another person? Y/N [delete] 53. Have you EVER worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Y/N 54. Have you EVER been a member of, assisted, 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? Y/N 55. Have you EVER served in, been a member of, assisted, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerilla group, militia, insurgent organization, or any other armed group? Y/N [Page 13] 56. Have you EVER been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party (in the United States or abroad)? Y/N 57. During the period from March 23, 1933 to May 8, 1945, did you ever order, incite, assist, or otherwise participate in the persecution of any person because of race, religion, national origin, or political opinion, in association with either the Nazi government of Germany or any organization or government associated or allied with the Nazi government of Germany? Y/N Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following: 58.a. Acts involving torture or genocide? Y/N 58.b. Killing any person? Y/N 58.c. Intentionally and severely injuring any person? Y/N 58.d. Engaging in any kind of sexual contact or relations with any person who did not consent or was unable to consent, or was being forced or threatened? Y/N 58.e. Limiting or denying any person’s ability to exercise religious beliefs? Y/N 59. Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group? Y/N 60. Have you EVER used any person under 15 years of age to take part in hostilities, or to help or provide services to people in combat? Y/N NOTE: If you answered “Yes” to any part of Item Numbers 52. - 60., explain what occurred, including the dates and location of the circumstances, in the space provided in Part 14. Additional Information. Public Charge Before responding to Item Numbers 61. and 62., please see Item 8. in the “How To Fill Out Form I-485” section of the General Instructions section and Item 9. in the What Evidence Must You Submit with Form I-485 section of the Instructions. Please visit www.uscis.gov/green-card/green-card-processes-and-procedures/public-charge and www.uscis.gov/news/fact-sheets/public-charge-fact-sheet. 61. Have you EVER been institutionalized for long-term care at government expense OR received any form of public cash assistance for income maintenance (for example, Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), or state or local cash assistance programs)? Y/N 62. Are you likely to be institutionalized for long-term care at government expense in the future OR receive public cash assistance for income maintenance (for example, TANF, SSI, or state or local cash assistance programs for income maintenance) in the future? Y/N Illegal Entries and other Immigration Violations 63.a. 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? Y/N If your answer to Item Number 63.a. is “Yes,” do you believe you had reasonable cause? Y/N 63.c. If your answer to Item Number 63.b. is “Yes,” attach a written statement explaining why you had reasonable cause. 64. Have you EVER submitted 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? Y/N 65. 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 kind of immigration benefit? Y/N 66. Have you EVER falsely claimed to be a U.S. citizen (in writing or any other way)? Y/N 67. Have you EVER been a stowaway on a vessel or aircraft arriving in the United States? Y/N 68. Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or to try to enter the United States illegally (alien smuggling)? Y/N 69. Are you under a final order of civil penalty for violating INA section 274C for use of fraudulent documents? Y/N Removal, Unlawful Presence, or Illegal Reentry After Previous Immigration Violations 70. 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? Y/N 71. Have you EVER entered the United States without being inspected and admitted or paroled? [Page 14] Since April 1, 1997, have you been unlawfully present in the United States: 72.a. For more than 180 days but less than a year, and then departed the United States? 72.b. For one year or more and then departed the United States? NOTE: You were unlawfully present in the United States if you entered the United States without being inspected and admitted or inspected and paroled, or if you legally entered the United States but you stayed longer than permitted. Since April 1, 1997, have you EVER reentered or attempted to reenter the United States without being inspected and admitted or paroled after: 73.a. Having been unlawfully present in the United States for more than one year in the aggregate? Y/N 73.b. Having been deported, excluded, or removed from the United States? Y/N Miscellaneous Conduct 74. Do you plan to practice polygamy in the United States? Yes/No 75. Are you accompanying another foreign national who requires your protection or guardianship but who is inadmissible after being certified by a medical officer as being helpless from sickness, physical or mental disability, or infancy, as described in INA section 232(c)? Yes/No 76. Have you EVER assisted in detaining, retaining, or withholding custody of a U.S. citizen child outside the United States from a U.S. citizen who has been granted custody of the child? Y/N 77. Have you EVER voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or regulation in the United States? Y/N 78. Have you EVER renounced U.S. citizenship to avoid being taxed by the United States? Y/N Have you EVER: 79.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 a foreign national? Y/N 79.b. Been relieved or discharged from such training or service on the ground that you are a foreign national? Y/N 79.c. Been convicted of desertion from the U.S. armed forces? 80.a. 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? Y/N 80.b, If your answer to Item Number 80.a. is “Yes,” 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)? _________
Page 5, Part 4. Accommodations for Individuals With Disabilities and/or Impairments	[Page 5] Part 4. Accommodations for Individuals With Disabilities and/or Impairments (See Page 7 of the instructions before completing this section.) Are you requesting an accommodation because of your disability(ies) and/or impairment(s)? Y/N 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):	[Page 14] Part 9. Accommodations for Individuals With Disabilities and/or Impairments NOTE: Read the information in the Form I-485 Instructions before completing this part. 1. Are you requesting an accommodation because of your disabilities and/or impairments? Yes/No If you answered “Yes” to Item Number 1., select any applicable box in Item Numbers 2.a. - 2.c. and provide an answer. 2.a. [ ] I am deaf or hard of hearing and request the following accommodation. (If you are requesting a sign-language interpreter, indicate for which language (for example, American Sign Language).): __________________________ 2.b. [ ] I am blind or have low vision and request the following accommodation: ________________________ [Page 15] 2.c. [ ] I have another type of disability and/or impairment. (Describe the nature of your disability and/or impairment and the accommodation you are requesting.) ________________________________
Page 5-6, Part 5. Signature	[Page 5] Part 5. Signature (Read the information on penalties on Page 8 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." [Page 6] 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 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. 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. Signature (Applicant) Print Your Full Name Date (mm/dd/yyyy) 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.	[Page 15] Part 10. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-485 Instructions before completing this part. You must file Form I-485 while in the United States. [delete] [delete] [delete] Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. [ ] I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. 1.b. [ ] The interpreter named in Part ­11. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything.  2. [ ] At my request, the preparer named in Part 12., [Fillable Field], prepared this application for me based only upon information I provided or authorized. Applicant’s Contact Information [Sub-header] 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) Applicant’s Declaration and Certification [Sub-header] Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I understand that if I am a male who is 18 to 26 years of age, submitting this application will automatically register me with the Selective Service System as required by the Military Selective Service Act. I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct. Applicant’s Signature [Sub-header] 6.a. Applicant’s Signature [Delete] 6.b. Date of Signature (mm/dd/yyyy) [Delete] [Delete] NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.
Page 6, Part 5. Interpreter’s Statement and Signature	[Page 6] Part 5. Signature (Read the information on penalties on Page 8 of the instructions before completing this section. You must file this application while in the United States.) 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) Daytime Phone Number (include area code)	[Page 16] Part 11. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter’s Full Name [sub header] 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter’s Mailing Address [sub header] 3.a. Street Number and Name 3.b. Apt. Ste. Flr. [fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter’s Contact Information [sub header] 4. Interpreter's Daytime Telephone Number 5. Interpreter’s Mobile Telephone Number (if any) 6. Interpreter’s Email Address (if any) Interpreter’s Certification [sub header] I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part 10., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant’s Declaration and Certification, and has verified the accuracy of every answer. [delete] Interpreter’s Signature [sub header] 7.a. Interpreter's Signature [delete] 7.b. Date of Signature (mm/dd/yyyy) [delete] [delete]
Page 6, Part 6. Signature of Person Preparing Form, If Other Than Above	[Page 6] 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 Print Your Full Name Date (mm/dd/yyyy) Daytime Phone Number (include area code) Firm Name and Address E-Mail Address (if any)	[Page 16] Part 12. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer’s Full Name [sub header] 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address [sub header] 3.a. Street Number and Name 3.b. Apt. Ste. Flr. [fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country [Page 17] Preparer’s Contact Information [sub-header] 4. Preparer’s Daytime Telephone Number 5. Interpreter’s Mobile Telephone Number (if any) 6. Interpreter’s Email Address (if any) Preparer’s Statement [sub-header] 7.a. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant’s consent. 7.b. I am an attorney or accredited representative and my representation of the applicant in this case [ ] extends [ ] does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer’s Certification [sub-header] By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant’s Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer’s Signature [sub header] 8.a. Preparer's Signature [delete] 8.b. Date of Signature (mm/dd/yyyy) [delete] [delete] [delete] [delete]
New		[Page 17] NOTE: Do not complete Part 13. until the USCIS Officer instructs you to do so at the interview. Part 13. Signature at Interview I swear (affirm) and certify under penalty of perjury under the laws of the United States of America that I know that the contents of this Form I-485, Application to Register Permanent Residence or Adjust Status, subscribed by me, including the corrections made to this application, numbered ___ through ___, are complete, true, and correct. All additional pages submitted by me with this Form I-485, on numbered pages ___ through ___ are complete, true, and correct. All documents submitted at this interview were provided by me and are complete, true, and correct. Subscribed to and sworn to (affirmed) before me USCIS Officer's Printed Name or Stamp Date of Signature (mm/dd/yyyy) Applicant's Signature USCIS Officer's Signature
New		[Page 18] Part 14. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application 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 Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Family Name (Last Name) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c.. Item Number 3.d. _________________________ 4.a. Page Number 4.b. Part Number 4.c.. Item Number 4.d. ________________________________ 5.a. Page Number 5.b. Part Number 5.c.. Item Number 5.d. _________________________________ 6.a. Page Number 6.b. Part Number 6.c.. Item Number 6.d. _______________________________ 7.a. Page Number 7.b. Part Number 7.c.. Item Number 7.d.

1