Form I-90 Application to Replace Permanent Resident Card

Application to Replace Permanent Resident Card
Department of Homeland Security
U.S. Citizenship and Immigration Services
Applicant Interviewed
Date:

USCIS
Form I-90
OMB No. 1615-0082
Expires 10/31/2017

Receipt

Action Block

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Class of Admission
For
USCIS
Use
Only Remarks

► START HERE - Type or print in black ink.

Part 1. Information About You
1.

Alien Registration Number (A-Number)

Mailing Address

6.a. In Care Of Name

A-

2.

USCIS Online Account Number (if any)
►

6.b. Street Number
and Name
6.c.

Your Full Name

NOTE: Your card will be issued in this name.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
4.

Apt.

Ste.

Flr.

6.d. City or Town
6.e. State

6.f.

ZIP Code

6.g. Province

6.h. Postal Code
6.i.

Country

Has your name legally changed since the issuance of your
Permanent Resident Card?
Yes (Proceed to Item Numbers 5.a. - 5.c.)

Physical Address

No (Proceed to Item Numbers 6.a. - 6.i.)

Provide this information only if different than mailing address.

N/A - I never received my previous card.
(Proceed to Item Numbers 6.a. - 6.i.)

7.a. Street Number
and Name

Provide your name exactly as it is printed on your current
Permanent Resident Card.
NOTE: Attach all evidence of your legal name change with
this application.

7.b.

Apt.

Flr.

7.c. City or Town
7.d. State

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

7.f.

5.c. Middle Name

7.h. Country

Form I-90 06/30/15 Y

Ste.

7.e. ZIP Code

Province

7.g. Postal Code

Page 1 of 7

Part 1. Information About You (continued)

Reason for Application (Select only one box)

Additional Information

Section A. (To be used only by a lawful permanent resident or
a permanent resident in commuter status.)

8.

Gender

Male

9.

Date of Birth

(mm/dd/yyyy) ►

10.

City/Town/Village of Birth

11.

Country of Birth

Mother's Name
12.

Given Name
(First Name)

Father's Name

Female

2.a.

My previous card has been lost, stolen, or destroyed.

2.b.

My previous card was issued but never received.

2.c.

My existing card has been mutilated.

2.d.

My existing card has incorrect data because of
Department of Homeland Security (DHS) error.
(Attach your existing card with incorrect data along
with this application.)

2.e.

My name or other biographic information has been
legally changed since issuance of my existing card.

2.f.

My existing card has already expired or will expire
within six months.

2.g.1.

I have reached my 14th birthday and am registering
as required. My existing card will expire AFTER my
16th birthday. (See NOTE below for additional
information.)

2.g.2.

I have reached my 14th birthday and am registering
as required. My existing card will expire BEFORE
my 16th birthday. (See NOTE below for additional
information.)

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13.

Given Name
(First Name)

14.

Class of Admission

15.

Date of Admission
(mm/dd/yyyy) ►

16.

U.S. Social Security Number (if any)

NOTE: If you are filing this application before your
14th birthday, or more than 30 days after your 14th
birthday, you must select reason 2.j. However, if
your card has expired, you must select reason 2.f.

►

Part 2. Application Type

2.h.1.

I am a permanent resident who is taking up commuter
status.

NOTE: If your conditional permanent resident status (for
example: CR1, CR2, CF1, CF2) is expiring within the next 90
days, then do not file this application. (See the What is the
Purpose of This Application section of the Form I-90
Instructions for further information.)

2.h.1.a.

My Port-of-Entry (POE) into the United States will be:
City or Town and State

2.h.2.

I am a commuter who is taking up actual residence in
the United States.

My status is (Select only one box):
1.a.

Lawful Permanent Resident (Proceed to Section A.)

2.i.

1.b.

Permanent Resident - In Commuter Status
(Proceed to Section A.)

I have been automatically converted to lawful
permanent resident status.

2.j.

I have a prior edition of the Alien Registration Card,
or I am applying to replace my current Permanent
Resident Card for a reason that is not specified above.

1.c.

Conditional Permanent Resident
(Proceed to Section B.)

Form I-90 06/30/15 Y

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Biographic Information

Part 2. Application Type (continued)
Section B. (To be used only by a conditional permanent resident.)
3.a.

My previous card has been lost, stolen, or destroyed.

3.b.

My previous card was issued but never received.

3.c.

My existing card has been mutilated.

3.d.

My existing card has incorrect data because of DHS
error. (Attach your existing permanent resident card
with incorrect data along with this application.)

3.e.

My name or other biographic information has legally
changed since the issuance of my existing card.

6.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

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7.

Race (Select all applicable boxes)
White
Asian
Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

8.

Height

9.

Weight

10.

Eye Color (Select only one box)

Feet

Inches

Part 3. Processing Information
1.

2.

Location where you applied for an immigrant visa or
adjustment of status:

Location where your immigrant visa was issued or USCIS
office where you were granted adjustment of status:

11.

Complete Item Numbers 3.a. and 3.a1. if you entered the
United States with an immigrant visa. (If you were granted
adjustment of status, proceed to Item Number 4.)

Pounds

Black
Gray

Blue

Brown

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Black
Gray
White

Blond
Red

Unknown/Other

3.a. Destination in the United States at time of admission

3.a.1. Port-of-Entry where admitted to the United States:
City or Town and State

4.

Have you ever been in exclusion, deportation, or removal
proceedings or ordered removed from the United States?
Yes

5.

No

Since you were granted permanent residence, have you
ever filed Form I-407, Abandonment by Alien of Status as
Lawful Permanent Resident, or otherwise been determined
to have abandoned your status?
Yes
No

NOTE: If you answered "Yes" to Item Numbers 4. or 5.
above, provide a detailed explanation in the space provided in
Part 8. Additional Information.

Form I-90 06/30/15 Y

Part 4. Accommodations for Individuals with
Disabilities and/or Impairments (Read the
information in the Form I-90 Instructions before
completing this part.)

NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
1.

Are you requesting an accommodation because of your
disabilities and/or impairments?
Yes
No

If you answered "Yes," select any applicable boxes:
1.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)):

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Part 4. Accommodations for Individuals with
Disabilities and/or Impairments (continued)
1.b.

Applicant's Contact Information

I am blind or have low vision and request the
following accommodation:

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

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5.

1.c.

Applicant's Email Address (if any)

Applicant's Certification

I have another type of disability and/or impairment
(Describe the nature of your disability and/or
impairment and the accommodation you are
requesting):

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 of my records that USCIS may need
to determine my eligibility for the immigration benefit I seek.
I further 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 laws.

Part 5. Applicant's Statement, Contact
Information, Certification, and Signature

I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:

NOTE: Read the Penalties section of the Form I-90
Instructions before completing this part.

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 6. read to me every
question and instruction on this application and my
answer to every question in

1) I reviewed and provided or authorized all of the
information in my application;
2) I understood all of the information contained in, and
submitted with, my application; and
3) All of this information was complete, true, and correct
at the time of filing.

I certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I 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

a language in which I am fluent and I understood
everything.
2.

6.a. Applicant's Signature

At my request, the preparer named in Part 7.,
,
prepared this application for me based only upon
information I provided or authorized.

Form I-90 06/30/15 Y

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.

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Part 6. Interpreter's Contact Information,
Certification, and Signature

Interpreter's Signature
7.a. Interpreter's Signature

Provide the following information about the interpreter.

Interpreter's Full Name

7.b. Date of Signature (mm/dd/yyyy) ►

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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)

Part 7. 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

Interpreter's Mailing Address

1.a. Preparer's Family Name (Last Name)

3.a. Street Number
and Name

1.b. Preparer's Given Name (First Name)

3.b.

Apt.

Ste.

3.c. City or Town
3.d. State
3.f.

Province

3.g. Postal Code
3.h. Country

Flr.

2.

Preparer's Business or Organization Name (if any)

3.e. ZIP Code

Preparer's Mailing Address

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town

Interpreter's Contact Information

3.d. State

4.

Interpreter's Daytime Telephone Number

3.f.

5.

Interpreter's Mobile Telephone Number (if any)

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country
6.

Interpreter's Email Address (if any)

Preparer's Contact Information
Interpreter's Certification

4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language provided in Part 5., 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 Certification, and has
verified the accuracy of every answer.
Form I-90 06/30/15 Y

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Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Statement

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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
does not extend beyond the
extends
preparation of this application.

NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this application, 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 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) ►

Form I-90 06/30/15 Y

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5.a. Page Number

Part 8. 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. Include 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.

Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

A-Number (if any)

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-

3.a. Page Number

3.d.

3.b. Part Number

3.c. Item Number

6.d.

7.a. Page Number

4.a. Page Number

4.b. Part Number

4.c. Item Number

7.d.

4.d.

Form I-90 06/30/15 Y

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