Page 3-4,
Part 2. Application
Type or Filing Category
|
[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.):
1.a.
Family-based
[]
Immediate relative of a U.S. citizen, 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
[]
Other relative of a U.S. citizen or relative of a lawful permanent
resident under the family-based preference categories, Form I-130
[]
VAWA self-petitioner, Form I-360
1.b.
Employment-based
[]
Alien entrepreneur, Form I-526
[]
Alien worker, Form I-140
1.c.
Special Immigrant
[]
Special immigrant juvenile, Form I-360
[]
Certain Afghan or Iraqi National, Form I-360 or Form DS-157
[]
Certain international broadcaster, Form I-360
[]
Certain G-4 international organization or family member or NATO-6
employee or family member, Form I-360
[]
Religious worker, Form I-360
1.d.
Asylee or Refugee
[]
Asylum status (INA section 208), Form I-589 or Form I-730
[]
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
[Page
4]
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 [Fillable
field]
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 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.
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) (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)
|
[Page 5]
Part 2. Application Type or
Filing Category
[deleted]
1. Are
you filing for adjustment of status with the Executive Office for
Immigration Review (EOIR) while in removal, exclusion, rescission,
or deportation proceedings?
Yes
No
2.
Receipt Number of Underlying Petition (if any)
Priority Date
from Underlying Petition (if any)
(mm/dd/yyyy)
I am filing
this Form I-485 as a (select only
one box):
[] Principal
Applicant
[] Derivative
Applicant (Provide the following information about the principal
applicant.)
Principal
Applicant's Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Principal
Applicant's A-Number (if any)
Principal
Applicant's Date of Birth
(mm/dd/yyyy)
I
am applying
based on the
following category
(You must select ONLY
ONE category.
If
you are filing as a derivative applicant, select the appropriate
box based on the category under which the principal applicant is
applying or has applied.
See the Form I-485
Instructions for more information, including any Additional
Instructions that
relate to the immigrant category you select.):
3.a.
Family-based
Immediate
relative of a U.S. citizen, Form I-130,
I-129F, or I-360 (select
your specific category below):
[]
Spouse of a U.S. citizen.
[]
Unmarried child under 21 years of age of a U.S. citizen.
[]
Parent of a U.S. citizen (if the citizen is at least 21 years of
age).
[] Person
admitted to the United States as a fiancé(e) or child of a
fiancé(e) of a U.S. citizen (K-1/K-2
Nonimmigrant).
[ ] Widow or
widower of a U.S. citizen.
[]
Spouse, child, or parent of a
deceased U.S. active-duty service member in the armed forces under
the National Defense Authorization Act (NDAA).
Other
relative of a U.S. citizen under the
family-based preference categories, Form I-130 (select
your specific category below):
[]
Unmarried son or daughter of a U.S. citizen and I am 21 years of
age or older.
[]
Married son or daughter of a U.S. citizen.
[]
Brother or sister of a U.S. citizen (if the citizen is at least 21
years of age).
Relative of a
lawful permanent resident under the family-based preference
categories, Form I-130 (select your specific category below):
[]
Spouse of a lawful permanent
resident.
[]
Unmarried child under 21 years of age of a lawful permanent
resident.
[]
Unmarried son or daughter of a lawful permanent resident and I am
21 years of age or older.
VAWA self-petitioner (victim
of battery or extreme cruelty), Form I-360 (select
your specific category below):
[]
VAWA self-petitioning spouse of a
U.S. citizen or lawful permanent resident.
[]
VAWA self-petitioning child of a U.S.
citizen or lawful permanent resident.
[]
VAWA self-petitioning parent of a
U.S. citizen (if the citizen is at least 21 years of age).
[Page 6]
3.b.
Employment-based
[] Alien
Investor, Form I-526
or Form I-526E
Alien
Workers, Form I-140 (select your
category below and answer the following questions below, as
applicable):
[]
Alien of Extraordinary Ability
[] Outstanding
Professor or Researcher
[]
Multinational Executive or Manager
[] Member of
the Professions Holding an Advanced Degree or Alien of Exceptional
Ability (who is NOT seeking a National Interest Waiver)
[] A
Professional (at a minimum, requiring a bachelor’s degree or
a foreign degree equivalent to a U.S. bachelor’s degree)
[] A Skilled
Worker (requiring at least 2 years of specialized training or
experience)
[] Any Other
Worker (requiring less than 2 years of training or experience)
[] An Alien
Applying For a National Interest Waiver (who IS a member of the
professions holding an advanced degree or an alien of exceptional
ability)
Did a relative
file the associated Form I-140 for you (or for the principal
applicant if you are a derivative applicant) or does a relative
have a significant ownership interest (5 percent or more) in the
business that filed Form I-140 for you (or for the principal
applicant, if you are a derivative applicant)?
[]
N/A (I am adjusting on the basis of a Form I-140 self-petition)
[] No
[] Yes
If you
answered “Yes,” is this relative your (select only
one box):
[] Father
[] Mother
[] Child
[] Adult
Son
[] Adult
Daughter
[] Brother
[] Sister
[] None of
These
Is the
relative above a:
[] U.S.
Citizen
[] U.S
National
[] Lawful
Permanent Resident
[] None of
These
3.c.
Special Immigrant
[] Special
Immigrant Juvenile, Form I-360
[] Certain
Afghan or Iraqi National, Form I-360 or Form DS-157
[] Certain
International Broadcaster, Form I-360
[] Certain
G-4 International Organization or
Family Member or NATO-6 Employee
or Family Member, Form I-360
[] Certain
U.S. Armed Forces Members (also known as the Six and Six program),
Form I-360
[] Panama
Canal Zone Employees, Form I-360
[] Certain
Physicians, Form I-360
[] Certain
Employee or Former Employee of the U.S. Government Abroad, DS-1884
Religious Worker,
Form I-360 (select your specific category
below):
[] Minister of
Religion
[] Other
Religious Worker
[Page 7]
3.d.
Asylee or Refugee
[] Asylum
Status (Immigration
and Nationality Act (INA) section
208), Form I-589 or Form I-730
If you
selected asylum, date you were granted asylum (mm/dd/yyyy).
[] Refugee
Status (INA section 207), Form I-590
or Form I-730
If you
selected refugee, date of initial admission as refugee
(mm/dd/yyyy).
3.e.
Human Trafficking Victim or Crime Victim
[] Human
Trafficking Victim (T Nonimmigrant),
Form I-914 or Derivative Family Member,
Form I-914A
[] Victim
of Qualifying Criminal Activity (U Nonimmigrant), Form
I-918, Derivative Family Member, Form
I-918A, or Qualifying Family Member,
Form I-929
3.f.
Special Programs Based on Certain Public Laws
[] The Cuban
Adjustment Act
[] A Victim of Battery or Extreme Cruelty as
a Spouse or Child Under the Cuban Adjustment Act
[] Applicant
Adjusting Based on Dependent Status Under the Haitian
Refugee Immigrant Fairness Act
[] A
Victim of Battery or Extreme Cruelty as a Spouse or Child Applying
Based on Dependent Status Under the Haitian Refugee
Immigrant Fairness Act
[] Lautenberg
Parolees
[] Diplomats
or High-Ranking Officials Unable to
Return Home (Section 13 of the Act of
September 11, 1957)
[] Nationals
of Vietnam, Cambodia, and Laos Applying for Adjustment of Status
Under section 586 of Public Law 106-429
[]
Applicant Adjusting Under the Amerasian Act (October 22, 1982),
Form I-360
3.g.
Additional Options
[] Diversity
Visa program
If you
selected Diversity Visa program, provide your Diversity Visa Rank
Number:
[] Continuous
Residence in the United States Since
Before January 1, 1972 ("Registry")
[] Individual
Born in the United States Under
Diplomatic Status
[]
S Nonimmigrants and Qualifying Family Members (can only adjust in
this category with an approved Form I-854B filed by a law
enforcement officer)
[] Other
Eligibility
[Fillable field]
[deleted]
4.
If you selected a
family-based, employment-based, special immigrant, or Diversity
Visa immigrant category listed above in Item
Numbers 3.a. - 3.g. as the basis for your application
for adjustment of status, are you
applying for adjustment based on INA
section 245(i)?
Yes
No
5.
Are you 21 years of age or older and applying for adjustment based
on classification as a child, under the provisions of the Child
Status Protection Act (CSPA)?
Yes
No
NOTE:
For more information to determine if you are eligible under CSPA,
see the Who May File Form I-485
section of
these Instructions.
[deleted]
|
Page
9-16,
Part
8. General Eligibility and Inadmissibility Grounds
|
[Page 9]
Part 8.
General Eligibility and Inadmissibility Grounds
Answer Item
Numbers 14. - 86.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.
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 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 Group
[Page 10]
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 Group
Dates of
Membership or Dates of Involvement
13.a. From
(mm/dd/yyyy)
13.b. To
(mm/dd/yyyy)
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?
Yes
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?
Yes
No
18. Are
you presently or have you EVER
been in removal, exclusion, rescission, or deportation
proceedings?
Yes
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. Have
you EVER
applied for any kind of relief or protection from removal,
exclusion, or deportation?
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
No
24.c. Have
you been granted a waiver or has Department of State issued a
favorable waiver recommendation letter for you?
Yes
No
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)?
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
[Page 11]
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
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
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?
Yes
No
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
No
32. Have
you EVER
illicitly (illegally) trafficked or benefited from the trafficking
of any controlled substances, such as chemicals, illegal drugs, or
narcotics?
Yes
No
33. Have
you EVER
knowingly aided, abetted, assisted, conspired, or colluded in the
illicit trafficking of any illegal narcotic or other controlled
substances?
Yes
No
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?
Yes
No
35. Have
you EVER
engaged in prostitution or are you coming to the United States to
engage in prostitution?
Yes
No
36. Have
you EVER
directly or indirectly procured (or attempted to procure) or
imported prostitutes or persons for the purpose of prostitution?
Yes
No
37. 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
40. Have
you EVER,
while serving as a foreign government official, been responsible
for or directly carried out violations of religious freedoms?
Yes
No
41. Have
you EVER
induced by force, fraud, or coercion (or otherwise been involved
in) the trafficking of persons for commercial sex acts?
Yes
No
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
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?
Yes
No
[Page 12]
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
46.e.
Engage in any other unlawful
activity?
Yes
No
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?
Yes
No
Have you EVER:
49. Have
you EVER
received any type of military, paramilitary, or weapons training?
Yes
No
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.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
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. Do
you intend to engage in any of the activities listed in any part
of Item Numbers 48.a. - 49.?
Yes
No
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
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
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
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
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. 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
[Page 13]
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?
Yes
No
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?
Yes
No
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/No
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?
Yes
No
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
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
58.e.
Limiting or denying any person's
ability to exercise religious beliefs?
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.
Public
Charge
61.
Are you subject to the public
charge ground of inadmissibility under INA section 212(a)(4)?
Yes
No
If you
answered “Yes” to
Item Number 61., complete Item
Numbers 62 - 68.d. below. If you
answered “No” to Item
Number 61., go to Item
Number 69.a. If you need extra
space to complete this section, use the space provided in Part
14. Additional Information.
62.
What is the size of your
household? [fillable field]
63.
Indicate your annual household income.
[]
$0-27,000
[]
$27,001-52,000
[]
$52,001-85,000
[]
$85,001-141,000
[]
Over $141,000
64.
Identify the total value of your household assets.
[]
$0-18,400
[]
$18,401-136,000
[]
$136,001-321,400
[]
$321,401-707,100
[]
Over $707,100
[Page 14]
65.
Identify the total value of your
household liabilities (including both secured and unsecured
liabilities).
[]
$0
[]
$1-10,100
[]
$10,101-57,700
[]
$57,701-186,800
[]
Over $186,800
66.
What is the highest degree or
level of school you have completed?
[]
Grades 1 through 11
[]
12th
grade – no diploma
[]
High school diploma, GED, or alternative credential
[]
1 or more years of college credit, no degree
[]
Associate’s degree
[]
Bachelor’s degree
[]
Master’s degree
[]
Professional degree (JD, MD, DMD, etc.)
[]
Doctorate degree
67.
List your certifications,
licenses, skills obtained through work experience, and educational
certificates.
[Fillable
table][1 column x 8 rows]
68.a.
Have you ever received
Supplemental Security Income (SSI), Temporary Assistance for Needy
Families (TANF), or State, Tribal, territorial, or local, cash
benefit programs for income maintenance (often called “General
Assistance” in the State context, but which also exist under
other names)?
Yes
No
68.b. Have
you ever received long-term institutionalization at government
expense?
Yes
No
68.c. If
your answer to Item Number 68.a.
is “Yes,” list the specific benefit(s) you received,
the start and end dates of each period of receipt, and the dollar
amount of benefits received.
[Fillable
table]
68.d. If
your answer to Item Number 68.b.
is “Yes,” list the name, city, and state for each
institution, the start and end dates of each period of
institutionalization, and the reason you were institutionalized.
[Fillable
table]
[Page 15]
Illegal
Entries and Other Immigration Violations
69.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?
Yes
No
69.b. If
your answer to Item Number 69.a.
is "Yes," do you believe you had reasonable cause?
Yes
No
69.c. If
your answer to Item Number 69.b.
is "Yes," attach a written statement explaining why you
had reasonable cause.
70. 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
71. 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
72. Have
you EVER
falsely claimed to be a U.S. citizen (in writing or any other
way)?
Yes
No
73. Have
you EVER
been a stowaway on a vessel or aircraft arriving in the United
States?
Yes
No
74. 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
75. Are
you under a final order of civil penalty for violating INA section
274C for use of fraudulent documents?
Yes
No
Removal,
Unlawful Presence, or Illegal Reentry After Previous Immigration
Violations
76. 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
No
77. Have
you EVER
entered the United States without being inspected and admitted or
paroled?
Yes
No
Since April 1,
1997, have you been unlawfully present in the United States:
78.a. For
more than 180 days but less than a year, and then departed the
United States?
Yes
No
78.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.
Since April 1,
1997, have you EVER reentered
or attempted to reenter the United States without being inspected
and admitted or paroled after:
79.a.
Having been unlawfully present in
the United States for more than one year in the aggregate?
Yes
No
79.b.
Having been deported, excluded,
or removed from the United States?
Yes
No
Miscellaneous
Conduct
80. Do
you plan to practice polygamy in the United States?
Yes
No
81. 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
82. 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
83. Have
you EVER
voted in violation of any Federal, state, or local constitutional
provision, statute, ordinance, or regulation in the United States?
Yes
No
84. Have
you EVER
renounced U.S. citizenship to avoid being taxed by the United
States?
Yes
No
Have you EVER:
85.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
[Page 16]
85.b. Been
relieved or discharged from such training or service on the ground
that you are a foreign national?
Yes
No
85.c. Been
convicted of desertion from the U.S. armed forces?
Yes
No
86.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
86.b. If
your answer to Item Number
86.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)?
[Fillable
field]
|
[Page 13]
Part 9.
General Eligibility and Inadmissibility Grounds
Choose the
answer that you think is correct in Part
9. 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.
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?
Yes
No
If you answered “Yes” to
Item Number 1., complete Item
Numbers 2. - 9.
If you were a member of more than two
organizations, use the space provided in Part 14.
Additional Information.
Organization 1
2. Name of Organization
3. City
or Town
State or
Province
Country
4. Nature of Organization,
including its purposes and activities, whether illicit or
legitimate.
Nature of
involvement in organization, including role or position(s) held,
whether illicit or legitimate.
[Page 14]
5.
Dates of Membership or Dates of Involvement
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
Organization 2
6. Name of Organization
[Page 14]
7. City
or Town
State or
Province
Country
8. Nature of Organization,
including its purposes and activities, whether illicit or
legitimate.
Nature of
involvement in organization, including role or position(s) held,
whether illicit or legitimate.
9.
Dates of Membership or Dates of Involvement
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
[deleted]
10.
Have you EVER been denied admission to the United
States?
Yes
No
11.
Have you EVER been denied a visa to the United States?
Yes
No
12.
Have you EVER worked in the United States without
employment authorization?
Yes
No
13.
Have you EVER violated the terms or conditions of your
nonimmigrant status?
Yes
No
14. Are
you presently or have you EVER been in removal, exclusion,
rescission, or deportation proceedings
including expedited removal proceedings?
Yes
No
15. Have
you EVER been issued a final order of exclusion,
deportation, or removal?
Yes
No
16. Have
you EVER had a prior final order of exclusion, deportation,
or removal reinstated?
Yes
No
[deleted]
17.
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
18.
Have you EVER applied for any kind of relief or
protection from removal, exclusion, or deportation?
Yes
No
19. Have
you EVER been a J nonimmigrant exchange visitor who was
subject to the two-year foreign residence requirement?
Yes
No
[deleted]
20.
If you answered “Yes” to
Item Number 19.,
have you complied with the
foreign residence requirement?
Yes
No
21.
If you answered “Yes” to
Item Number 19.
and “No” to Item
Number 20., have you been
granted a waiver or has Department of State issued a favorable
waiver recommendation letter for you?
Yes
No
Criminal
Acts and Violations
For Item
Numbers 22. - 41., 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 22.
- 41., use the space provided in Part 14. Additional
Information to provide an explanation
for each offense, if applicable, that includes a
description of the criminal offense; where the criminal offense
occurred; when the criminal offense occurred; whether you were
arrested, cited, charged, or detained for the criminal offense you
committed; and the outcome or disposition
of that criminal offense (for example, convicted,
placement in a diversion program, no charges filed, charges
dismissed, jail, prison, detention,
probation, or community
service). Your explanation must include the
duration of any sentence to confinement (even if suspended).
22.
Have you EVER been arrested, cited,
charged, or permitted to participate in a diversion program
(including pre-trial diversion, deferred prosecution, deferred
adjudication, or any withheld adjudication), or detained
for any reason by any law enforcement official in
any country including but not limited to any U.S.
immigration official or any official of the U.S. armed forces or
U.S. Coast Guard or by a similar official of
a country other than the United States?
Yes
No
[Page 15]
23.
Have you EVER committed a crime of any kind
(even if you were not arrested, cited, charged with,
or tried for that crime, or
convicted)?
Yes
No
24.
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
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.
25.
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
[deleted]
26.
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
No
27.
Have you EVER trafficked
in or benefited from, or knowingly aided, abetted, assisted,
conspired or colluded in the illegal trafficking of any controlled
substances, such as chemicals, illegal drugs, or narcotics?
Yes
No
[deleted]
28. 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 5 years,
any financial or other benefit from this
activity of your spouse or parent?
Yes
No
29.
If your answer to Item
Number 28. is “Yes,”
did you know or should you have reasonably known that the
financial or other benefit you obtained resulted from this
activity of your spouse or parent?
Yes
No
30. Have
you EVER engaged in prostitution or are you coming to the
United States to engage in prostitution?
Yes
No
31. Have
you EVER directly or indirectly procured
or attempted to procure, or imported
prostitutes or persons for the purpose of prostitution?
Yes
No
32. Have
you EVER received any proceeds or money from prostitution?
Yes
No
33. 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
34. Have
you EVER exercised immunity (diplomatic or otherwise) to
avoid being prosecuted for a criminal offense in the United
States?
Yes
No
35.a. Have
you EVER
served as a foreign government official?
Yes
No
35.b.
If your answer to Item Number
35.a. is “Yes,” have
you EVER
been responsible for, enforced, or directly carried out violations
of religious freedoms?
Yes
No
36.
Have you EVER induced by force, fraud, or
coercion (or otherwise been involved in) the trafficking of
another person for commercial sex
acts (sex trafficking)?
Yes
No
NOTE:
Sex trafficking involves inducing or causing an adult to engage in
a commercial sex act (any sex act performed for anything of value)
through fraud, force, or coercion, or inducing or causing any
person under 18 years of age to engage in a commercial sex act
(even without force, fraud, or coercion). Sex trafficking may
include recruiting, enticing, harboring, transporting, providing,
obtaining, advertising, maintaining, patronizing, or soliciting by
any means a person to engage in the commercial sex act knowing
(or, in the case of advertising, with reckless disregard of the
fact) that the person is under 18 years of age or that force,
fraud, or coercion was used to induce or cause the person to
engage in the commercial sex act. Sex trafficking may also include
knowingly benefitting financially or by receiving anything of
value, from participation in a venture involving sex trafficking.
37. 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
[Page 16]
38. Have
you EVER knowingly aided, abetted, assisted, conspired, or
colluded with others in trafficking in
persons for commercial sex acts or involuntary servitude,
peonage, debt bondage, or slavery?
Yes
No
39.
Are you the spouse, son,
or daughter of a foreign national who engaged in the trafficking
in persons and have received or
obtained, within the last 5 years,
any financial or other benefits from this
activity of your spouse or your parent?
Yes
No
40.
If your answer is “Yes” to Item
Number 39., did you know or
reasonably should have known that this benefit resulted from this
activity of your spouse or parent?
Yes
No
41.
Have you EVER engaged in money laundering or
have you EVER knowingly aided, assisted, abetted,
conspired, or colluded with others in money laundering or do you
seek to enter the United States to engage in such activity?
Yes
No
Security and Related
Do you intend to:
42.a.
Engage in any activity that violates or evades any law
relating to espionage (including spying) or sabotage in the United
States?
Yes
No
42.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
42.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
[deleted]
42.d.
Engage in any other unlawful activity?
Yes
No
[deleted]
Have you EVER:
43.a.
Received
any weapons training, paramilitary training, or other
military-type training?
Yes
No
43.b.
Committed kidnapping,
assassination, or hijacking or sabotage of a conveyance (including
an aircraft, vessel, vehicle, or train)?
Yes
No
43.c.
Used a weapon or explosive or any dangerous device with the intent
to endanger the safety of another person or people or cause damage
to property?
Yes
No
43.d.
Threatened, attempted, conspired,
prepared, or planned to do any of the things described in Item
Numbers 43.b. - 43.c.?
Yes
No
43.e.
Incited, under circumstances indicating an intention to cause
death or serious bodily harm/injury, any of the activities
described in Item Numbers 43.b. -
43.c.?
Yes
No
43.f.
Participated in, or been a member of, a group or
organization that did any of the activities described in
Item Numbers
43.b. - 43.e.?
Yes
No
43.g.
Recruited members or asked for money or things of value
for a group or organization that did any of the activities
described in Item Numbers
43.b. - 43.e.?
Yes
No
43.h.
Provided money, a thing of value, services or labor, or
any other assistance or support for any of the activities
described in Item Numbers
43.b. - 43.e.?
Yes
No
43.i.
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
Numbers 43.b.
- 43.e.?
Yes
No
44. Do
you intend to engage in any of the activities listed in any part
of Item Numbers
43.b. - 43.e.?
Yes
No
45. Do
you intend to engage in any activity that could endanger the
welfare, safety, or security of the United States?
Yes
No
NOTE:
If you answered “Yes” to any part of Item
Numbers 42.a. - 45.,
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.
[Page 17]
46.
Are you the spouse or child of an individual who EVER
engaged in any of the activities
listed in Item Numbers
43.b. - 43.i.?
Yes
No
NOTE: If
you answered “Yes” to any part of Item
Number 46., explain what your
parent or spouse did, including the dates and location of the
circumstances in Part 14.
Additional Information.
[deleted]
47.
Have you EVER sold,
provided, or transported
weapons, or assisted any person in selling,
providing, or transporting weapons, which you knew or believed
would be used against another person?
Yes
No
48. Have
you EVER worked, volunteered, or otherwise served in any
prison, jail, prison camp, detention facility, labor camp, or any
other place where people were detained, or
have you EVER
directed or participated in any other activity that involved
detaining people?
Yes
No
49. 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?
Yes
No
50. Have you EVER
served in, been a member of, assisted (helped),
or participated in any military or police
unit?
Yes
No
51.
Have you EVER
served in, been a member of, assisted (helped), or participated in
any armed group (a group that carries weapons), for example:
paramilitary unit (a group of people who act like a military
group, but are not part of the official military), self-defense
unit, vigilante unit, rebel group, or guerrilla group?
Yes
No
If you
answered “Yes” to Item
Number 50. or 51.,
include the name of the country, the name of the military unit or
armed group, your rank or position, and your dates of involvement
in your explanation in Part 14.
Additional Information.
52.
Have you EVER been a member of, or in any way
affiliated with, the Communist Party or any
totalitarian party (in the United States or abroad)?
Yes
No
[deleted]
Have
you EVER ordered, incited, called for, committed, assisted,
helped with, or otherwise participated in any of the following:
53.a.
Torture?
Yes
No
53.b.
Genocide?
Yes
No
53.c.
Killing, or trying to kill, any
person?
Yes
No
53.d.
Intentionally and severely injuring or
trying to injure any person?
Yes
No
[deleted]
54.
Have you EVER recruited, enlisted, conscripted,
or used any person under 15 years of age to take
part in hostilities or to serve in or help an armed force
or group, or attempted or worked with others
to do so?
Yes
No
55.
Have you EVER used any person under 15 years of
age to take part in hostilities, for
instance, participating in combat or providing services related to
combat (such as sabotage or serving as a courier) or providing
support services (such as transporting supplies), or attempted or
worked with others to do so?
Yes
No
NOTE:
If you answered “Yes” to any part of Item Numbers
47. - 55., explain
what occurred, including the dates and location of the
circumstances, in the space provided in Part 14. Additional
Information.
[Page
18]
Public
Charge
Each
noncitizen who is subject to the public charge ground of
inadmissibility in INA section 212(a)(4) must complete Item
Numbers 57. - 66.
A noncitizen is subject to the public charge ground of
inadmissibility if the noncitizen does not fall under one of the
categories exempt from the public charge ground of inadmissibility
listed below. If you fall under one of the exempt categories
listed below, please select the exempt category, and skip Item
Numbers 57. - 66. If you do not
fall under one of the exempt categories listed below, select “I
do not fall under any of the exempt categories listed above and
will complete Item Numbers 57. -
66.”
NOTE:
For more information, see Part 9.
General Eligibility and Inadmissibility Grounds, Public
Charge section of these
Instructions.
56. I am
exempt from the public charge ground of inadmissibility because I
am a/an (select only one
box):
[
] VAWA Self-Petitioner (Form I-360)
[
] Special Immigrant Juvenile (Form I-360)
[
] Certain Afghan or Iraqi National (Form I-360 or Form DS-157)
[
] Asylee (Form I-589 or Form I-730)
[
] Refugee (Form I-590 or Form I-730)
[
] Victim of Qualifying Criminal Activity (U Nonimmigrant) under
INA section 245(m) (Form I-918, Form I-918A, or Form I-929)
[
] Any category other than INA section 245(m), but you are in valid
U nonimmigrant status at the time you file your application for
adjustment of status. (This exemption only applies if, at the time
of the adjudication of Form I-485, you are still in valid U
nonimmigrant status. If, at the time of adjudication of Form
I-485, you are no longer in valid U nonimmigrant status, you will
be subject to the public charge ground of inadmissibility.)
[
] Human Trafficking Victim (T nonimmigrant) under INA section
245(l) (Form I-914 or Form I-914A)
[
] Any category other than INA section 245(l), but you either have
a pending application for T nonimmigrant status (Form I-914) that
sets forth a prima facie case for eligibility or are in valid T
nonimmigrant status at the time you file your application for
adjustment of status. (This exemption only applies if your Form
I-914 is still pending and deemed to be prima facie eligible or
you are in valid T nonimmigrant status when we adjudicate your
adjustment of status application.)
[
] Cuban Adjustment Act
[
] 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
[
] Cuban and Haitian Entrants Applying for Adjustment of Status
under section 202 of the Immigration Reform and Control Act of
1986
[
] A Lautenberg Parolee
[
] National of Vietnam, Cambodia, or Laos Applying under the
Foreign Operations, Export Financing, and Related Programs
Appropriations Act of 2001
[
] Continuous Residence in the United States Since Before January
1, 1972 (“Registry”)
[
] Amerasian Homecoming Act
[
] Polish or Hungarian Parolee
[
] Nicaraguans and Other Central Americans under section 203 of the
Nicaraguan Adjustment and Central American Relief Act (NACARA)
[
] American Indian Born in Canada (INA section 289) or the Texas
Band of Kickapoo Indians of the Kickapoo Tribe of Oklahoma, Public
Law 97-429 (Jan. 8, 1983)
[
] Section 7611 of the National Defense Authorization Act for
Fiscal Year 2020 (Liberian Refugee Immigration Fairness)
[Page 19]
[
] Syrian National Adjusting Status under Public Law 106-378
[
] Spouse, Child, or Parent of a U.S. Active-Duty Service Member in
the Armed Forces under the National Defense Authorization Act
(NDAA) (Form I-130 or Form I-360)
[
] I do not fall under any of the exempt categories listed above
and will complete Item Numbers 57.
- 66.
If
you selected “I do not fall
under any of the exempt categories listed above and will complete
Item Numbers 57. - 66.”
in
Item Number 56., complete Item
Numbers 57. - 66. below. If you
selected an exempt category in
Item Number 56., go to Item
Number 67. If
you need extra space to complete this section, use the space
provided in Part 14. Additional
Information.
57.
What is the size of your
household? [fillable field]
58.
Indicate your annual household income.
[]
$0-27,000
[]
$27,001-52,000
[]
$52,001-85,000
[]
$85,001-141,000
[]
Over $141,000
59.
Identify the total value of your household assets.
[]
$0-18,400
[]
$18,401-136,000
[]
$136,001-321,400
[]
$321,401-707,100
[]
Over $707,100
60.
Identify the total value of your
household liabilities (including both secured and unsecured
liabilities).
[]
$0
[]
$1-10,100
[]
$10,101-57,700
[]
$57,701-186,800
[]
Over $186,800
61.
What is the highest degree or
grade of
school you have completed?
[]
Less than a high school
diploma. If you select this option,
indicate the highest grade of school you have completed. [fillable
field]
[]
High school diploma, GED, or alternative credential
[]
1 or more years of college credit, no degree
[]
Associate’s degree
[]
Bachelor’s degree
[]
Master’s degree
[]
Professional degree (JD, MD, DMD, etc.)
[]
Doctorate degree
62.
List your certifications,
licenses, skills obtained through work experience, and educational
certificates.
[Fillable
table][1 column x 8 rows]
63. Have
you ever received Supplemental Security Income (SSI), Temporary
Assistance for Needy Families (TANF), or state,
Tribal, territorial, or local cash
benefit programs for income
maintenance (often called “General Assistance” in the
state context,
but which also exist under other names)?
Yes
No
64.
Have you ever received long-term
institutionalization at government expense?
Yes
No
[Page 20]
65.
If your answer to Item
Number 63.
is “Yes,” list the specific benefit(s) you received,
the start and end dates of each period of receipt,
the dollar amount of benefits
received, and whether you received
the benefits while you were in an immigration category exempt from
the public charge ground of inadmissibility.
[Fillable
table- Last column should have yes/no
checkboxes]
66.
If your answer to Item
Number 64.
is “Yes,” list the name, city, and state for each
institution, the start and end dates of each period of
institutionalization, the reason
you were institutionalized, and
whether you were institutionalized while you were in an
immigration category exempt from the public charge ground of
inadmissibility.
[Fillable table-
Last column should have yes/no checkboxes]
Illegal Entries and Other
Immigration Violations
67.
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?
Yes
No
NOTE:
If your answer to Item Number 67.
is “Yes,” attach a written statement
explaining why you failed or refused to
attend or remain in attendance at the removal proceeding,
including any explanation of a reasonable cause for that failure
or refusal.
[deleted]
68. Have
you EVER submitted altered,
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
69. 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 immigration benefit?
Yes
No
70. Have
you EVER falsely claimed to be a U.S. citizen (in writing
or any other way)?
Yes
No
71. Have
you EVER been a stowaway on a vessel or aircraft arriving
in the United States?
Yes
No
72. 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
73.
Are you under a final order of civil penalty for
violating INA section 274C for use of fraudulent documents?
Yes
No
Removal, Unlawful Presence, or
Illegal Reentry After Previous Immigration Violations
74. 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
No
75. Have
you EVER entered the United States without being inspected
and admitted or paroled?
Yes
No
[Page 21]
76. Since
April 1, 1997, have you been unlawfully present in the United
States? You
were unlawfully present in the United States if you were present
in the United States after the expiration of the period of stay
authorized by the Department of
Homeland Security (DHS) Secretary or
were present in the United States without being admitted or
paroled.
Yes
No
NOTE: If
you answered “Yes” to Item
Number 76., give the dates of
unlawful presence in the space provided in Part
14. Additional Information.
77. If
you answered “Yes” to Item
Number 76., was a severe form of
trafficking in persons at least one central reason for your
unlawful presence in the United States?
Yes
No
NOTE: Severe
trafficking in persons involves sex trafficking (the recruitment,
harboring, transportation, provision, or obtaining of a person to
commit a commercial sex act) induced by force, fraud, coercion, or
in which the person is induced to perform such act has not reached
18 years of age, or the recruitment, harboring, transportation,
provision, or obtaining of a person for labor or services, through
the use of force, fraud, or coercion for the purpose of subjection
to involuntary servitude, peonage, debt bondage, or slavery.
[deleted]
Since
April 1, 1997, have you EVER reentered or attempted to
reenter the United States without being inspected and admitted or
paroled after:
78.a.
Having been unlawfully present in the United States for
more than one year in the aggregate on or
after April 1, 1997? You were
unlawfully present in the United States for more than one year in
the aggregate if you count all of the days during all of your
stays that you were present in the United States after the
expiration of the period of stay authorized by the DHS Secretary
or were present in the United States without being admitted or
paroled.
Yes
No
78.b.
Having been deported, excluded, or removed from the
United States?
Yes
No
Miscellaneous Conduct
79. Do
you plan to practice polygamy in the United States?
Yes
No
80. Are
you accompanying an alien who is
inadmissible and who has been certified by a medical officer as
helpless from sickness, mental or physical disability, or infancy,
and who requires your protection or guardianship, as
described in INA section 232(c)?
Yes
No
81. Have
you EVER assisted in detaining, retaining, or withholding
custody of a U.S. citizen child outside the United States from a
person who has been granted custody
of the child?
Yes
No
82. Have
you EVER voted in violation of any Federal, state, or local
constitutional provision, statute, ordinance, or regulation in the
United States?
Yes
No
83. Have
you EVER renounced U.S. citizenship to avoid being taxed by
the United States?
Yes
No
Have you EVER:
84.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
84.b. Been
relieved or discharged from such training or service on the ground
that you are a foreign national?
Yes
No
84.c. Been
convicted of desertion from the U.S. armed forces?
Yes
No
85. 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
86.
If your answered “Yes”
to Item Number 85.,
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)?
[Fillable field]
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