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pdfApplication to Register Permanent Residence
or Adjust Status
USCIS
Form I-485
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0023
Expires 10/31/2017
For USCIS Use Only
Receipt
Preference Category:
Action Block
Country Chargeable:
Priority Date:
Date Form I-693 Received:
Applicant
Interviewed
Date of
Initial Interview:
Lawful Permanent
Resident as of:
Interview
Waived
Section of Law
DRAFT
NOT FOR
PRODUCTION
07/25/2016
INA 209(a)
INA 209(b)
INA 245(a)
INA 245(i)
INA 245(m)
INA 249
Sec. 13, Act of 9/11/57
Cuban Adjustment Act
Other
To be completed by an attorney or accredited representative (if any).
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)
A-Number ► A-
► 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)
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
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
7.
City or Town of Birth
Male
Female
2.c. Middle Name
Form I-485 10/05/15 Y
Page 1 of 18
A-Number ► A-
Part 1. Information About You (Person applying
for lawful permanent residence) (continued)
8.
Country of Birth
9.
Country of Citizenship or Nationality
10.
Alien Registration Number (A-Number) (if any)
► A-
USCIS Online Account Number (if any)
►
12.
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)
DRAFT
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PRODUCTION
07/25/2016
NOTE: If you have EVER used other A-Numbers,
include the additional A-Numbers in the space provided
in Part 14. Additional Information.
11.
Recent Immigration History
U.S. Social Security Number (if any)
►
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
U.S. Mailing Address
20.b. State
13.a. In Care Of Name (if any)
21.
13.b. Street Number
and Name
13.c.
Apt.
13.d. City or Town
13.e. State
When I last arrived in the United States, I:
Ste.
Flr.
22.a.
Was inspected at a port of entry and admitted.
22.b.
Was inspected at a port of entry and paroled.
22.c.
Came into the United States without admission or
parole.
22.d.
Came into the United States without admission or
parole, but I was later paroled.
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 crime victim (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)
Apt.
Ste.
If you selected Item Numbers 22.a., 22.b., or 22.d.:
23.a. Form I-94 Arrival-Departure Record Number (if any)
►
23.b. Form I-94 Number expiration date
(mm/dd/yyyy)
23.c. Status on Form I-94 (for example, class of admission, if
admitted or paroled, if paroled)
14.b. Street Number
and Name
14.c.
Date of Last Arrival (mm/dd/yyyy)
Flr.
24.
What is your current immigration status (if it has changed
since your arrival)?
14.d. City or Town
14.e. State
14.f. ZIP Code
Form I-485 10/05/15 Y
Page 2 of 18
A-Number ► A-
Part 1. Information About You (Person applying
for lawful permanent residence) (continued)
1.d. Asylee or Refugee
Asylum status (INA section 208), Form I-589 or
Form I-730
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)
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
25.c. Middle Name
Crime victim (U Nonimmigrant), Form I-918,
derivative family member, Form I-918A, or
qualifying family member, Form I-929
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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.
1.f.
Special Programs Based on Certain Public Laws
The Cuban Adjustment Act
The Cuban Adjustment Act for battered spouses and
children
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.):
Dependent status under the Haitian Refugee
Immigrant Fairness Act
Dependent status under the Haitian Refugee
Immigrant Fairness Act for battered spouses and
children
1.a. Family-based
Immediate relative of a U.S. citizen, Form I-130
Lautenberg Parolees
Other relative of a U.S. citizen or relative of a lawful
permanent resident under the family-based preference
categories, Form I-130
Diplomats or high ranking officials unable to return
home (Section 13 of the Act of September 11, 1957)
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)
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")
Widow or widower of a U.S. citizen, Form I-360
VAWA self-petitioner, Form I-360
Individual born in the United States under diplomatic
status
1.b. Employment-based
Alien worker, Form I-140
Other eligibility
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 family
member or NATO-6 employee or family member,
Form I-360
Form I-485 10/05/15 Y
2.
Are you applying for adjustment based on the
Immigration and Nationality Act (INA) section 245(i)?
Yes
No
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. 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 3 of 18
A-Number ► A-
Part 2. Application Type or Filing Category
(continued)
Information About Your Immigrant Category
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)
3.
Decision (for example: approved, refused, denied,
withdrawn)
4.
Date of Decision (mm/dd/yyyy)
Address History
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.
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PRODUCTION
07/25/2016
(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.
Physical Address 1 (current address)
Principal Applicant's Name
5.b.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
6.
Apt.
Ste.
Flr.
5.c. City or Town
5.d. State
5.f.
Principal Applicant's A-Number (if any)
► A-
7.
5.a. Street Number
and Name
Principal Applicant's Date of Birth
5.e. ZIP Code
Province
5.g. Postal Code
5.h. Country
(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)
Dates of Residence
6.a. From (mm/dd/yyyy)
6.b. To (mm/dd/yyyy)
Physical Address 2
Part 3. Additional Information About You
7.a. Street Number
and Name
1.
Have you ever applied for an immigrant visa to obtain
permanent resident status at a U.S. Embassy or U.S.
Consulate abroad?
Yes
No
7.b.
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.
7.d. State
Apt.
Ste.
Flr.
7.c. City or Town
7.f.
7.e. ZIP Code
Province
Location of U.S. Embassy or U.S. Consulate
7.g. Postal Code
2.a. City
7.h. Country
2.b. Country
Form I-485 10/05/15 Y
Page 4 of 18
A-Number ► A-
Part 3. Additional Information About You
(continued)
Address of Employer or Company
Dates of Residence
12.b.
8.a. From (mm/dd/yyyy)
Apt.
9.c. City or Town
9.d. State
9.f.
Province
9.g. Postal Code
9.h. Country
Dates of Residence
Flr.
12.e. ZIP Code
12.f. Province
12.g. Postal Code
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12.h. Country
Ste.
Flr.
13.
9.e. ZIP Code
10.a. From (mm/dd/yyyy)
Your Occupation
Dates of Employment
14.a. From (mm/dd/yyyy)
14.b. To (mm/dd/yyyy)
Employer 2
15.
Name of Employer or Company
Address of Employer or Company
10.b. To (mm/dd/yyyy)
16.a. Street Number
and Name
Employment History
16.b.
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.
16.c. City or Town
Employer 1 (current or most recent)
11.
Ste.
12.d. State
Provide your most recent address outside the United States
where you lived for more than one year (if not already listed
above).
9.b.
Apt.
12.c. City or Town
8.b. To (mm/dd/yyyy)
9.a. Street Number
and Name
12.a. Street Number
and Name
Name of Employer or Company
Apt.
Ste.
16.d. State
Flr.
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)
Form I-485 10/05/15 Y
Page 5 of 18
A-Number ► A-
Part 3. Additional Information About You
(continued)
Provide your most recent employment outside of the United
States (if not already listed above).
19.
Name of Employer or Company
Address of Employer or Company
20.a. Street Number
and Name
20.b.
Apt.
20.c. City or Town
20.d. State
20.f. Province
20.g. Postal Code
20.h. Country
3.
Date of Birth (mm/dd/yyyy)
4.
Sex
5.
City or Town of Birth
6.
Country of Birth
7.
Current City or Town of Residence (if living)
Male
Female
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Ste.
Flr.
20.e. ZIP Code
8.
Current Country of Residence (if living)
Information About Your Parent 2
Parent 2's Legal Name
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c. Middle Name
21.
Your Occupation
Dates of Employment
22.a. From (mm/dd/yyyy)
22.b. To (mm/dd/yyyy)
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)
Part 4. Information About Your Parents
12.
Sex
Information About Your Parent 1
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)
Male
Female
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
Form I-485 10/05/15 Y
Page 6 of 18
A-Number ► A-
Part 5. Information About Your Marital History
1.
What is your current marital status?
Single, Never Married
Widowed
Married
Divorced
Marriage Annulled
Legally Separated
2.
3.
If you are married, is your spouse a current member of the
U.S. armed forces or U.S. Coast Guard?
N/A
Yes
No
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?
Yes
How many times have you been married (including
annulled marriages and marriages to the same person)?
No
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Information About Prior Marriages (if any)
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.
11.c. Middle Name
► A-
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.b. State or Province
8.c. Country
Form I-485 10/05/15 Y
Prior Spouse's Legal Name (provide family name before
marriage)
11.a. Family Name
(Last Name)
11.b. Given Name
(First Name)
A-Number (if any)
8.a. City or Town
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.
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 7 of 18
A-Number ► A-
Part 5. Information About Your Marital History
(continued)
Child 2
Current Legal Name
7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)
Place Where Marriage with Prior Spouse Legally Ended
16.a. City or Town
7.c. Middle Name
16.b. State or Province
8.
A-Number (if any)
► A-
16.c. Country
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9.
Date of Birth (mm/dd/yyyy)
10.
Country of Birth
Indicate the total number of children (including adult sons
and daughters) that you have.
11.
Is this child applying with you?
NOTE: Include all of your living children, including
children of any age; children born in the United States or
in other countries; children who are currently married or
unmarried; children living with you or elsewhere; current
stepchildren; legally adopted children; children born when
you were not married; and missing children (Do not
include deceased children).
Child 3
Part 6. Information About Your Children
1.
Yes
No
Yes
No
Current Legal Name
12.a. Family Name
(Last Name)
12.b. Given Name
(First Name)
12.c. Middle Name
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.
13.
A-Number (if any)
► A-
14.
Date of Birth (mm/dd/yyyy)
15.
Country of Birth
16.
Is this child applying with you?
Part 7. Biographic Information
A-Number (if any)
1.
► A4.
Date of Birth (mm/dd/yyyy)
5.
Country of Birth
Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino
2.
Race (Select all applicable boxes)
White
6.
Is this child applying with you?
Yes
No
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Form I-485 10/05/15 Y
Page 8 of 18
A-Number ► A-
Part 7. Biographic Information (continued)
3.
Height
4.
Weight
5.
Eye Color (Select only one box)
6.
Feet
Inches
Pounds
Dates of Membership or Dates of Involvement
5.a. From (mm/dd/yyyy)
5.b. To (mm/dd/yyyy)
Organization 2
Black
Blue
Brown
Gray
Green
Hazel
Maroon
Pink
Unknown/Other
6.
Name of Organization
7.a. City or Town
Hair Color (Select only one box)
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Bald (No hair)
Black
Blond
Brown
Gray
Red
White
Unknown/Other
Sandy
7.b. State or Province
7.c. Country
Part 8. General Eligibility and Inadmissibility
Grounds
8.
1.
Dates of Membership or Dates of Involvement
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. 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
Nature of Group
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 Group
Dates of Membership or Dates of Involvement
13.a. From (mm/dd/yyyy)
4.
Nature of Group
Form I-485 10/05/15 Y
13.b. To (mm/dd/yyyy)
Page 9 of 18
A-Number ► A-
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
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.
14.
Have you EVER been denied admission to the United
States?
Yes
No
15.
Have you EVER been denied a visa to the United States?
No
16.
Have you EVER worked in the United States without
authorization?
Yes
No
17.
Have you EVER violated the terms or conditions of your
nonimmigrant status, including a student nonimmigrant
visa?
Yes
No
Are you presently or have you EVER been in removal,
exclusion, rescission, or deportation proceedings?
Yes
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)?
Yes
No
26.
Have you EVER committed a crime of any kind (even if
you were not arrested, cited, charged with, or tried for that
crime)?
Yes
No
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)?
Yes
No
No
19.
Have you EVER been issued a final order of exclusion,
deportation, or removal?
Yes
No
20.
Have you EVER had a prior final order of exclusion,
deportation, or removal reinstated?
Yes
No
21.
Have you EVER held lawful permanent resident status
which was later rescinded?
Yes
No
22.
Have you EVER been granted voluntary departure by an
immigration officer or an immigration judge but failed to
depart within the allotted time?
Yes
No
23.
Criminal Acts and Violations
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Yes
18.
24.c. Have you been granted a waiver or has Department of
State issued a favorable waiver recommendation letter for
you?
Yes
No
Have you EVER applied for any kind of relief or
protection from removal, exclusion, or deportation?
Yes
No
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)?
Yes
No
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)?
Yes
No
24.a. Have you EVER been a J nonimmigrant exchange visitor
who was subject to the two-year foreign residence
requirement?
Yes
No
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?
Yes
Form I-485 10/05/15 Y
No
Page 10 of 18
A-Number ► A-
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
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?
Yes
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?
Yes
No
32.
Have you EVER illicitly (illegally) trafficked or
benefited from the trafficking of any controlled
substances, such as chemicals, illegal drugs, or narcotics?
No
Have you EVER engaged in prostitution or are you
coming to the United States to engage in prostitution?
Yes
37.
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.
Yes
No
No
Have you EVER directly or indirectly procured (or
attempted to procure) or imported prostitutes or persons
for the purpose of prostitution?
Yes
No
Have you EVER received any proceeds or money from
prostitution?
Yes
No
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?
Yes
No
39.
Have you EVER exercised immunity (diplomatic or
otherwise) to avoid being prosecuted for a criminal
offense in the United States?
Yes
No
Form I-485 10/05/15 Y
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?
Yes
No
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?
Yes
No
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?
No
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?
Yes
36.
Have you EVER induced by force, fraud, or coercion (or
otherwise been involved in) the trafficking of persons for
commercial sex acts?
Yes
No
No
Have you EVER knowingly aided, abetted, assisted,
conspired, or colluded in the illicit trafficking of any
illegal narcotic or other controlled substances?
Yes
35.
41.
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Yes
34.
Have you EVER, while serving as a foreign government
official, been responsible for or directly carried out
violations of religious freedoms?
Yes
No
No
31.
33.
40.
Yes
No
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?
Yes
No
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?
Yes
No
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?
Yes
No
46.d. Engage in any activity that could endanger the welfare,
safety, or security of the United States?
Yes
No
Page 11 of 18
A-Number ► A-
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
46.e. Engage in any other unlawful activity?
47.
Yes
No
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?
Yes
No
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?
Yes
No
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.?
Yes
No
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.?
Yes
No
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.?
Yes
No
50.
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.?
Yes
No
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.?
Yes
No
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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.?
Yes
No
49.
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.?
Yes
No
Have you EVER received any type of military,
paramilitary, or weapons training?
Yes
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.?
Yes
No
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.
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?
Yes
No
Have you EVER assisted or participated in selling,
providing, or transporting weapons to any person who, to
your knowledge, used them against another person?
Yes
No
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?
Yes
No
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?
No
Do you intend to engage in any of the activities listed in
any part of Item Numbers 48. - 49.?
Yes
No
Form I-485 10/05/15 Y
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.?
Yes
No
Yes
55.
No
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?
Yes
No
Page 12 of 18
A-Number ► A-
Public Charge
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
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)?
Yes
57.
61.
Yes
No
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?
Yes
No
Have you EVER received any form of public assistance
in the United States from any source, including the U.S.
Government or any state, country, city, or municipality
(other than emergency medical treatment)?
62.
No
Are you likely to receive public assistance in the future?
Yes
No
Illegal Entries and Other Immigration Violations
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63.
Have you EVER failed or refused to attend or to remain
in attendance at your removal, exclusion, or deportation
proceeding?
Yes
No
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?
Yes
No
65.
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?
Yes
No
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?
Yes
No
66.
Have you EVER falsely claimed to be a U.S. citizen (in
writing or any other way)?
Yes
No
58.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No
67.
Have you EVER been a stowaway on a vessel or aircraft
arriving in the United States?
Yes
No
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)?
Yes
No
69.
Are you under a final order of civil penalty for violating
INA section 274C for use of fraudulent documents?
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?
Yes
No
58.b. Killing any person?
Yes
No
58.c. Intentionally and severely injuring any person?
Yes
No
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?
Yes
No
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?
Yes
No
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.
Yes
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?
Yes
71.
Form I-485 10/05/15 Y
No
No
Have you EVER entered the United States without being
inspected and admitted or paroled?
Yes
No
Page 13 of 18
A-Number ► A-
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
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?
Yes
No
72.b. For one year or more and then departed the United States?
Yes
No
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.
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?
Yes
No
79.b. Been relieved or discharged from such training or service
on the ground that you are a foreign national?
Yes
No
79.c. Been convicted of desertion from the U.S. armed forces?
Yes
No
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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?
Yes
No
73.b. Having been deported, excluded, or removed from the
United States?
Yes
No
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
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)?
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.
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?
Yes
No
77.
Have you EVER voted in violation of any Federal, state,
or local constitutional provision, statute, ordinance, or
regulation in the United States?
Yes
No
78.
Have you EVER renounced U.S. citizenship to avoid
being taxed by the United States?
Yes
No
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.
No
76.
Form I-485 10/05/15 Y
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?
Yes
No
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 14 of 18
A-Number ► A-
Applicant's Declaration and Certification
Part 9. Accommodations for Individuals With
Disabilities and/or Impairments (continued)
2.c.
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 I seek.
I have another type of disability and/or impairment.
(Describe the nature of your disability and/or
impairment and the accommodation you are
requesting.)
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.
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Part 10. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
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.
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.
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:
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
a language in which I am fluent, and I understood
everything.
2.
,
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
Form I-485 10/05/15 Y
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
At my request, the preparer named in Part 12.,
prepared this application for me based only upon
information I provided or authorized.
1)
,
6.a. Applicant's Signature
6.b. Date of Signature (mm/dd/yyyy)
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 15 of 18
A-Number ► A-
Part 11. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
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.
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Interpreter's Business or Organization Name (if any)
Interpreter's Signature
7.a. Interpreter's Signature
Interpreter's Mailing Address
7.b. Date of Signature (mm/dd/yyyy)
3.a. Street Number
and Name
3.b.
Apt.
3.c. City or Town
3.d. State
3.f.
Province
3.g. Postal Code
3.h. Country
Ste.
Flr.
3.e. ZIP Code
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
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
Interpreter's Contact Information
4.
Interpreter's Daytime Telephone Number
5.
Interpreter's Mobile Telephone Number (if any)
6.
Interpreter's Email Address (if any)
2.
Preparer's Business or Organization Name (if any)
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.
Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
3.e. ZIP Code
Province
3.g. Postal Code
3.h. Country
Form I-485 10/05/15 Y
Page 16 of 18
A-Number ► A-
Part 12. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
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
Preparer's Contact Information
corrections made to this application, numbered
4.
through
Preparer's Daytime Telephone Number
, are complete, true, and correct. All
additional pages submitted by me with this Form I-485, on
5.
6.
Preparer's Mobile Telephone Number (if any)
numbered pages
through
are complete,
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Preparer's Email Address (if any)
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
Preparer's Statement
7.a.
7.b.
I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.
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.
Date of Signature (mm/dd/yyyy)
Applicant's Signature
USCIS Officer's Signature
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
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
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
NOTE: Do not complete Part 13. until the USCIS Officer
instructs you to do so at the interview.
Form I-485 10/05/15 Y
Page 17 of 18
A-Number ► A5.a. Page Number
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)
1.b. Given Name
(First Name)
1.c. Middle Name
2.
5.b. Part Number
5.c. Item Number
5.d.
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6.a. Page Number
6.b. Part Number
6.c. Item Number
7.b. Part Number
7.c. Item Number
A-Number (if any) ► A-
3.a. Page Number
3.d.
3.b. Part Number
3.c. Item Number
6.d.
7.a. Page Number
7.d.
4.a. Page Number
4.b. Part Number
4.c. Item Number
4.d.
Form I-485 10/05/15 Y
Page 18 of 18
| File Type | application/pdf |
| File Modified | 2016-08-04 |
| File Created | 2016-07-23 |