Form DS-5540 PUBLIC CHARGE QUESTIONNAIRE

U.S. Department of State

OMB CONTROL NO. 1405-0234
EXPIRES: 08/31/2020
ESTIMATED BURDEN: 4.5 hours

PUBLIC CHARGE QUESTIONNAIRE
PART 1 - INFORMATION ABOUT YOU
1. Your Current Legal Name (Do not provide a nickname)
Family Name (Last Name)

Given Name (First Name)

Middle Name

2. Date of Birth (mm-dd-yyyy)

3. Have you ever been to the United States before?
Yes

No

PART 2 - YOUR HEALTH
4. Do you currently have health insurance coverage in the United States?
Yes

No

If you answered "Yes" to Item number 4, attach evidence of health insurance and skip to Part 3.
If you answered "No" to Item number 4, proceed to Item A.
4A. Will you be covered by health insurance in the United States within 30 days of your entry into the United States?
Yes

No

If you answered "yes" to Item A, identify the specific health insurance plan and date coverage will begin.

PART 3 - YOUR HOUSEHOLD SIZE
List the expected members of your household in the United States.

Name

Age

Relationship to you

Current Job

United States
Citizen
(yes / no)

Was he or she on active duty,
other than training, in the U.S.
Armed Forces or Ready
Reserve while receiving a
public benefit?
(yes / no)

PART 4 - YOUR ASSETS, RESOURCES, AND FINANCIAL STATUS
6. List below all U.S. federal tax returns you have filed within the last three years and attach your IRS transcript (or copy of the complete, filed tax
return) for your most recent U.S. federal tax return.
Federal Tax Year

Did you file a Federal tax return?
Yes

No

Yes

No

Yes

No

Yes

No

Gross Income (U.S. dollars)

7. Did you work in the United States in the last three years but not file a U.S. federal tax return?
Yes

No

If you answered "yes", explain.

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8. Income
8A. What is your current yearly compensation
in U.S. dollars?

8B. If you currently have a job awaiting your arrival in the United States, who is the employer and
what is the yearly compensation in U.S. dollars?

8C. List below any income not listed above that you will continue to receive after your arrival in the United States (for example, rent, stock dividends,
foreign pension, child support). Consular Officers may request additional information or evidence for confirmation.

How often do you receive this income? (annually,
monthly, etc.)

Type of Income

Amount (U.S. Dollars)

Total

9. List the assets available to you in the table below. For example, cash assets may include checking and savings accounts, etc. Non-cash assets may
include equity in real estate, annuities, securities, etc.
Type of Asset

Location of Asset

Amount (U.S. Dollars)

Total

10. List your liabilities and/or debts in the table below.

Type of Liability or Debt

Amount (U.S. Dollars)

Total

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11. For purposes of this form, a public benefit means any of the following forms of assistance received on or after February 24, 2020: 1) Any Federal,
state, local, or tribal cash assistance for income maintenance, including supplemental security income (SSI) and Temporary Assistance for Needy
Families (TANF); 2) Supplemental Nutrition Assistance Program (SNAP); 3) Housing Choice Voucher Program; 4) Project-Based Rental Assistance
(including Moderate Rehabilitation); 5) Subsidized Housing; or 6) Medicaid, except for benefits received for an emergency medical condition, services
or benefits funded by Medicaid but provided under the Individuals with Disabilities Education Act (IDEA), school-based services or benefits provided to
individuals of secondary school age, benefits received by an alien under 21 years of age, or benefits received by a woman during pregnancy or during
the 60-day period beginning on the last day of the pregnancy.
Have you or any of the individuals applying with you covered by this form requested or received public benefits in the United States from a Federal, state, local, or tribal
government entity on or after February 24, 2020?
Yes

No

If you answered "Yes," provide the information below.

Type of Benefit

Agency That Grants The Benefit

11A.
Date Benefit Was
Granted (mm-dd-yyyy)

Date Benefit Ended or
Expires (mm-dd-yyyy)

Reason For Requesting or Receiving The Benefit

Type of Benefit

Agency That Grants The Benefit

11B.
Date Benefit Was
Granted (mm-dd-yyyy)

Date Benefit Ended or
Expires (mm-dd-yyyy)

Reason For Requesting or Receiving The Benefit

Type of Benefit

Agency That Grants The Benefit

11C.
Date Benefit Was
Granted (mm-dd-yyyy)

Date Benefit Ended or
Expires (mm-dd-yyyy)

Reason For Requesting or Receiving The Benefit

12. If you or your family requested or received a public benefit, were you or your family members exempt from public charge during that period?
Yes

No

If you answered "Yes," provide an explanation.

13. Are you likely to request or receive any of the public benefits described in Question 11 in the future in the United States from any Federal, state,
local, or tribal government entity?
Yes

No

If you answered "Yes," provide an explanation.

14. Have you ever received a fee waiver when applying for an immigration benefit from USCIS?
Yes

No

If you answered "Yes," provide the information in the table below. In Part 8 - Additional Information, explain the circumstances that caused you to apply
for a fee waiver and if those circumstances have changed.

Date Fee Waiver Received (mm/dd/yyyy)

Type of Immigrant Benefit (Form Number)

Receipt Number

PART 5 - YOUR EDUCATION AND SKILLS
15. Have you graduated high school or earned a high school equivalent diploma?
Yes

No

If you answered "No," then list the highest grade completed.
If you answered "Yes," list any other educational degrees you have earned..

16. Do you have any occupational skills?
Yes

No

If you answered "Yes," provide the information below.

Certification/License Type/Occupational Skill

Date Obtained (mm/dd/yyyy)

16A.
Who issued your license? (if any)

License Number (if any)

Certification/License Type/Occupational Skill

Expiration/Renewal Date (if any)

Date Obtained (mm/dd/yyyy)

16B.
Who issued your license? (if any)

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License Number (if any)

Expiration/Renewal Date (if any)

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Certification/License Type/Occupational Skill

Date Obtained (mm/dd/yyyy)

16C.
Who issued your license? (if any)

License Number (if any)

Expiration/Renewal Date (if any)

PART 6 - TRANSLATOR
17. Did you use a translator to help you complete this form? (If yes, provide the following information about the translator you used.)
Yes

No

17A. Translator's Name
Family Name (Last Name)

Given Name (First Name)

Middle Name

17B. Translator's Business or Organization name? (if any)

17C. Translator's Street Address

17D. Translator's City

17E. Translator's State/Province

17F. Translator's Postal/Zip Code

17H. Translator's Phone Number

17G. Translator's Country

17I. Translator's Email Address

PART 7 - PREPARER
18. Did anyone, other than a translator, help you complete this form? (If yes, provide the following information about the preparer you used.)
Yes

No

18A. Preparer's Name
Family Name (Last Name)

Given Name (First Name)

Middle Name

18B. Preparer's Business or Organization name? (if any)

18C. Preparer's Street Address

18D. Preparer's City

18E. Preparer's State/Province

18F. Preparer's Postal/Zip Code

18H. Preparer's Phone Number

18G. Preparer's Country

18I. Preparer's Email Address

PART 8 - ADDITIONAL INFORMATION (if needed)
If further space is required, attach additional sheets. Please ensure you specify to what question(s) you are responding.
PART 9 - DECLARANT'S SIGNATURE
I understand all the information I have provided in, or in support of, this application may be provided to other U.S. government agencies authorized to use such information
for purposes including enforcement of the laws of the United States. I understand all of the information contained in this form and I certify under penalty of perjury under the
laws of the United States of America that the foregoing is complete, true, and correct. I understand that any willfully false or misleading statement or willful concealment of a
material fact made by me herein may result in refusal of the visa, denial of admission to the United States, and may subject me to criminal prosecution and/or removal from
the United States.

Signature

Date

Name (Printed)
Federal Agency Disclosure and Authorizations
PAPERWORK REDUCTION ACT STATEMENT:
Public reporting burden for this collection of information is estimated to average 4.5 hours per response, including time required for searching existing data sources,
gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information
unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it,
please send them to: PRA_BurdenComments@state.gov.
CONFIDENTIALITY STATEMENT:
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment, administration,
or enforcement of the immigration, nationality, and other laws of the United States. Visa records may be disclosed in certain situations, as described in INA Section 222(f),
including disclosure to a court as needed in a case pending before the court.

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