Ds 7656 Form PDF Details

Form DS-7666 is a U.S. visa application form used by individuals who want to travel to the United States for business or pleasure. The form is also used by those who want to visit the U.S. temporarily and apply for a change of status while in the country. The DS-7666 form must be completed in English and can be downloaded from the U.S. Department of State website. Instructions on how to complete the form can also be found on this website. Completing the DS-7666 form accurately is important, as it will help determine if you are eligible for a U.S. visa and what type of visa you may be granted. Let's take a closer look at what information is required on the DS-7666 form and how it should be completed correctly. Form DS-7666 isn't used often but knowing about it could save your trip! This article walks through each question with tips on filling out this US Visa application Form step by step!

QuestionAnswer
Form NameDs 7656 Form
Form Length17 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 15 sec
Other namesmississippi affidavit of relationship, ds 7656, rel resided resettlement, u mmm online

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U.S. Department of State

INSTRUCTIONS - DS-7656, AFFIDAVIT OF RELATIONSHIP (AOR)

NOTE: Read these instructions carefully. If you do not follow the instructions, the U.S. Department of State, or its designated representative, may return your AOR for clarification or correction. By completing this form you are claiming a relationship with family members overseas in order to assist the U.S. Government in determining whether those family members are qualified to apply for admission to the United States under the U.S. Refugee Admissions Program (USRAP). The AOR itself is not an application on behalf of your family member for admission to the U.S. as a refugee under the USRAP or a petition for any immigration benefit under U.S. law. Completion of this AOR does not guarantee that your family members will be found qualified to apply for refugee admission or that they ultimately will be admitted to the United States. Additionally, the information listed in this AOR may be used and disclosed by the U.S. Department of State as described in the Privacy Act Statement on the AOR and in Part 10 of these instructions below. The U.S. Government investigates claimed family relationships and verifies the validity of documents. Criminal prosecutions may be sought when family relationships are falsified to obtain immigration benefits.

1. Purpose of This Form

The DS-7656 provides a means for persons in the United States who were admitted as refugees or were granted asylum to claim a relationship with certain family members overseas and to assist the U.S. Department of State in determining whether those family members are qualified to apply for access to the USRAP for family reunification purposes. The specific family relationships and nationalities eligible for consideration under USRAP vary from year to year as outlined in the annual Presidential Report to Congress on Proposed Refugee Admissions. Resettlement agency representatives, who assist persons with this form, are knowledgeable about who may file an AOR in the current year. This form also assists the U.S. Department of Homeland Security's U.S. Citizenship and Immigration Services (USCIS) to verify family relationships during refugee case adjudication. The main purpose of the DS-7656 is for you (the Anchor Relative) to provide biographical information about relatives overseas who may subsequently seek access to the USRAP for verification by the U.S. Government. The information on this form may also be used by the U.S. Government to verify information provided by these individuals in relation to any other immigration benefit they may subsequently seek under U.S. law and other uses as described in the Privacy Act Statement on the AOR and in Part 10 of these instructions below.

2. Who May File This Affidavit?

You may file the DS-7656 if you are at least 18 years of age, have been admitted to the United States as a refugee or granted asylum in the United States no more than five years prior to the filing of this affidavit, and have a legal immigration status in the United States. This includes persons who were admitted as refugees or granted asylum and are now Lawful Permanent Residents (LPR), and, in some circumstances, U.S. Citizens.

3. Who Is Qualified to Apply for Refugee Admission Based on this AOR?

Your spouse, and/or your unmarried child(ren) under 21 years of age, and/or your parents, may be qualified to apply for refugee admission to the United States under the USRAP. Please list them in Section II part A. of the AOR as the Qualifying Family Member.

Spouses and unmarried children under 21 years of age of Qualifying Family Members may be included on the Qualifying Family Member’s refugee application and may be admitted as derivative beneficiaries with the Qualifying Family Member as a refugee if otherwise admissible to the United States. These individuals derive their refugee status from the Qualifying Family Member and do not have to independently establish a persecution claim. Please list them in Section II of the AOR as type B relatives.

On a case-by-case basis, an individual may also be considered qualified to apply for admission in connection with a Qualifying Family Member if that individual:

1.lived in the same household as the Qualifying Family Member in the country of nationality or, if stateless, last habitual residence; AND,

2.was part of the same economic unit as the Qualifying Family Member in the country of nationality or, if stateless, last habitual residence; AND,

3.demonstrates exceptional and compelling humanitarian circumstances that justify his/her inclusion on the Qualifying Family Member’s case.

These individuals cannot derive their refugee status from the Qualifying Family Member and therefore must independently establish that they qualify as a refugee. Please list them in Section II of the AOR as type C relatives.

Please note:

- The relationship between you and the Qualifying Family Member must have existed on the date you were admitted to the United States as a refugee, or granted asylum in the United States, and must continue to exist.

- If a person who is listed on this form is a child who was conceived but not yet born on the date you were admitted to the United States as a refugee, or granted asylum in the United States, the relationship will be considered to exist as of the date you were admitted to the United States as a refugee, or granted asylum in the United States. The mother of any such child is not a Qualifying Family Member unless the mother was married to you when you were admitted to the United States as a refugee, or granted asylum in the United States.

- The marriage creating a stepparent or stepchild relationship must have occurred before the child's 18th birthday in order for the stepparent or stepchild to be claimed in this AOR as a Qualifying Family Member or derivative.

- Adopted Children: In order to be claimed on this AOR as Qualifying Family Members in Section II or as a type B relative in Section II, adopted children must have been in the legal custody of and resided with the adopting parent or parents for at least two years and:

1.been legally adopted before their 16th birthday, or

2.be the natural sibling of a child described in (1) directly above and been adopted themselves before their 18th birthday.

-In all cases, in order for your children/stepchildren/adopted children to be considered Qualifying Family Members, they must be unmarried and under 21 years of age when the AOR is filed and continue to be unmarried at the time of admission to the U.S. at the port of entry.

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4. Where Do You File This Form?

The DS-7656 is prepared by you with assistance from a local resettlement agency participating in the Department of State's Refugee Reception and Placement Program, and submitted to the U.S. Department of State by the agency's national headquarters office. AORs submitted directly to

Resettlement Support Centers (RSCs) or by you to the U.S. Government will NOT be accepted.

5. What Additional Information Must Be Provided With the DS-7656?

You must attach copies of documents that provide proof of your current legal immigration status in the United States. AORs submitted without such

document(s) will NOT be accepted.

Acceptable Proof of Legal Status:

a.Refugees and Asylees: Legible copy of both sides of your I-94, or a copy of your asylum grant letter, or immigration judge grant decision.

b.Permanent Residents: Legible copy of both sides of I-551(Permanent Resident Card - Green Card), or any temporary proof of permanent resident status issued by the Department of Homeland Security's USCIS (or documents that were formerly issued by the Immigration and

Naturalization Service.)

c.U.S. Citizens: Legible copy of your U.S. Passport or Naturalization Certificate (Note: it is now legal to make a copy of this document for

immigration purposes.)

If you are filing for an adopted child, please provide a copy of the adoption papers, if available.

6. What Additional Information May Need to be Provided to Establish a Family Relationship?

You and your biological parents and children listed in Section II of the AOR will be required to provide a DNA sample at a later date to establish your relationship. By signing your name on the AOR, you are agreeing to provide the DNA sample when requested by an official of the U.S. Government, or its designated representatives. Further, by signing the AOR you are expressing your understanding that DNA testing could be requested between your Qualifying Family Member(s) and their derivative beneficiaries. Please note that if you or your claimed family members fail to submit DNA evidence upon request, your family members may be considered ineligible for refugee resettlement.

An officer of USCIS will make the final determination regarding whether a bona fide relationship exists between you and your relative(s) at the time of the interview for refugee status.

7. Who will Pay the Costs of DNA Testing?

You and/or your Qualifying Family Member(s) must pay all costs associated with DNA testing of both you and your Qualifying Family Member(s). In addition, you and/or your Qualifying Family Member(s) will be expected to pay the costs of any additional testing between your Qualifying Family Member(s) and their derivative beneficiaries. The U.S. Government will reimburse the cost of DNA testing if such tests confirm claimed biological relationships.

8. What Are the General Instructions for Completing the AOR?

The DS-7656 must be completed in English. Please complete using Cerenade fill program. Handwritten applications will be returned. If you need extra space to complete any item, attach a separate continuation sheet. Indicate the item number, and date and sign each sheet.

Answer all questions fully and accurately. If you do not know the answer to a question, please write "Unknown". If questions asked do not apply to you, please state "N/A", meaning Not Applicable. For all persons, where the Date of Birth is not known, please provide an estimate and check the box; if the City/Country of Birth is not known, please provide the best guess and then explain in Section IV.

Please use the relationship codes provided at the end of this document to indicate relationships between persons, as requested on this form.

Please upload a passport style photo for each Qualifying Family Member listed in Section II. Frame the photo as a front view of the applicant’s full face, from the top of the head to the shoulders with eyes open. Upload the photo in a .bmp or .tif format.

You are responsible for providing detailed information to the best of your knowledge. If you do not have all the information required BUT you can obtain the information needed, please wait to complete the AOR until all of the information is received.

Ages and other dates: Always give exact dates of birth and of significant events, like marriage, if they are known. If you can give a best-estimated date, please provide the best-estimated date and check the appropriate box.

Each Section of the AOR must be fully completed. The address of your relatives overseas must be as complete as possible. Provide the name of the refugee camp if applicable. Provide a phone number if it is known.

If a family member is deceased or the present location of the family member is unknown, please indicate, and give the date of death or last contact in the "Current or Last Known City/Country" column.

Be sure to include all relatives requested by the AOR form anywhere in the world, whether living, deceased or missing, in Section III. Use Section IV Additions/Explanations to explain any non-biological relationships, including adoptive or foster relationships.

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Names: Use a complete name each time a name is requested. Do not use initials. If the person has a patronymic, substitute the patronymic for the middle name. If the middle name of the person has only one letter, or if there is any different naming structure, this should be clarified in Section IV Additions/Explanations. If anyone uses an alias, provide that information in Section IV or on a supplemental sheet.

All Dates on the AOR: All dates must comply with the following format: DD MMM YYYY (14 JAN 1965).

If there is insufficient space in any Section, please continue in Section IV or use supplemental sheets.

No agency representative or other USRAP processing partner may solicit or accept money or any other favor in order to prepare, file, or process the DS-7656.

9. What Are the Penalties for Committing Fraud?

Title 8, United States Code, Section 1325, states that any person who knowingly enters into a marriage contract for the purpose of evading any provision of the immigration laws shall be imprisoned for not more than five years, or fined not more than $250,000, or both.

Title 18, United States Code, Section 1001, states that whoever willfully and knowingly falsifies a material fact, makes a false statement or makes use of a false document will be fined up to $10,000 or imprisoned up to five years, or both.

If it is determined that a genuine relationship does not exist between you and the person(s) you are claiming as your relative(s), then processing of their admission to the United States as a refugee(s), and that of their family members, may be terminated.

Misrepresenting your relationship to an individual(s) so that such individual(s) may gain access to the refugee program could make you inadmissible to the United States, make you ineligible for certain immigration benefits, and/or render you subject to removal.

10. What Is Our Authority for Collecting This Information and How May We Use It?

The U.S. Department of State requests the information on this form, including the agreement of the anchor relative to provide a DNA sample at a later date, to carry out the immigration laws contained in Title 8, United States Code, Section 1157. The U.S. Department of State requests this information to assist in determining whether a family member claimed on this form is qualified to apply for access to the U.S. Refugee Admissions Program (USRAP) for purposes of family reunification. The information you provide may also be disclosed to a) the U.S. Department of Homeland Security for purposes of determining whether your relatives are eligible for admission to the United States and for verifying information provided by the family members listed on this form in any application they may make for admission to the United States under the USRAP or for any other immigration benefit under U.S. law; b) Members of Congress or other Federal, State, and local government agencies having statutory or other lawful authority, as needed for the formulation, amendment, administration, or enforcement of immigration, nationality, and other laws of the United States; and, c) international organizations and resettlement agency partners that work with the USRAP to enable them to coordinate and manage refugee processing overseas and resettlement in the United States. You do not have to complete this form and provide the requested information; however, if you refuse to give some or all of it, your relative's access to the USRAP for refugee resettlement consideration may be denied.

11. Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of State, PRM/A, 2025 E Street, NW Washington DC, 20520. OMB No. 1405-0206.

HOW TO FILL OUT THIS FORM

SECTION I: INFORMATION ABOUT YOU, THE ANCHOR

This section is for information about you. You must be at least 18 years of age to file an AOR.

a.Enter your full name.

b.Enter your date of birth: DD MMM YYYY (day, month, year; 14 JAN 1965).

c.Enter your sex: M or F.

d.Enter your marital status: single (S), married (M), divorced (D), separated (P), widow/widower (W).

e.Enter the name of your current spouse.

f.Provide your city and country of birth.

g.Provide your current U.S. address.

h.Provide your home telephone number, work telephone number and cellular phone number.

i.Provide your e-mail address.

j.Provide your date of arrival in the United States (if refugee) or Date Asylum was granted (if asylee): DD MMM YYYY (date, month, year; 14 JAN 1965)

k.

Provide your current U.S. citizenship/immigration status and provide your Certificate of Naturalization Number (if applicable).

l.If you arrived as a refugee, provide information about where you were processed as a refugee (if applicable), your overseas case number (if known) and the name of the agency that processed your case overseas (if known). If not known, please write "unknown".

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SECTION II: INFORMATION ABOUT QUALIFYING FAMILY MEMBERS SEEKING ACCESS TO THE USRAP

This section is for the Qualifying Family Members you are claiming a relationship with to support their access to the USRAP so they may apply for admission to the United States as a refugee. Other relatives should be listed in Section III.

Please use a separate page for each Qualifying Family Member you are claiming. List the Qualifying Family Member's dependents and any members of household/economic unit on that page. You may use as many pages as necessary to include each Qualifying Family Member you are claiming.. Please use the List of Relationship Codes to indicate the requested relationships in the "Relationship to Anchor" and "Relationship to Qualifying Family Member Listed Above" columns.

Line 1: Please provide the requested information only for a spouse, parent, or unmarried child under age 21. If the Date of Birth is not known, please estimate and check the box; if the City/Country of Birth is not known, please provide the best guess and then explain in Section IV. If the answer to other questions is not known, please write "unknown." If a question is not applicable, please write N/A.

Please provide the contact information for the person listed on Line 1 where requested.

Line 2-20: Please list from oldest to youngest, the spouse and/or unmarried children under age 21 of the qualifying family member named on line 1 who wish to be considered for resettlement at this time. Please enter "B" in the box under "Type" to specify that this person is a derivative of the qualifying family member. If applicable, please also include individuals who were part of the same household/economic unit of the qualifying family member named on Line 1, and explain the exceptional and compelling circumstances justifying the inclusion in the AOR in the Comments box. For these individuals, enter "C" in the box under "Type" to specify that this person is a member of the same economic unit as the qualifying family member named on line 1. If the Date of Birth is not known, please estimate and check the box; if the City/County of Birth is not known, please provide the best guess and then explain in Section IV.

SECTION III: INFORMATION ABOUT ALL OF YOUR RELATIVES NOT PREVIOUSLY PROVIDED IN SECTION II

This section is for all your relatives anywhere in the world, whether living, deceased or missing, that were NOT previously listed in Section II. Please remember that these relatives are not being considered for access to the USRAP.

Please use the List of Relationship Codes to indicate the requested relationships in the “Relationship to Anchor” columns.

(A)Please provide information about your biological parents that was NOT previously provided in Section II.

(B)Please provide information about all your adoptive parents, stepparents, or foster parents that was NOT previously provided in Section II

(C)Please provide information about your spouse and all previous spouses that was NOT previously provided in Section II.

(D)Please provide information about all your children (including biological, adopted, step and foster children) from oldest to youngest that was NOT previously provided in Section II.

(E)Please provide information about all your brothers and sisters (including biological, adopted, step and foster brothers and sisters) from oldest to youngest that was NOT previously provided in Section II.

SECTION IV: ADDITIONS/EXPLANATIONS

Please use this section to elaborate on any extended or non-traditional relationships that may require further explanation (including adopted, half, and step relatives), any unusual name patterns, any aliases, or any unusual circumstances that you wish to address. Please also use this section as a continuation page for any other sections that had insufficient space.

SECTION V: SIGNATURES

Please read the certification and then sign your name, print your name, and fill in the date. You will be asked to provide valid identification to the resettlement agency representative who assisted you to fill out this form. The resettlement agency representative will then sign the form, print his/her name, date the form, and provide the affiliate name, address and telephone number.

By Submitting this Affidavit of Relationship I understand that I and Qualifying Family Members (parents, spouse, unmarried children under age 21) will be requested to submit DNA evidence. I further understand that DNA testing could be suggested between my Qualifying Family Member(s) and their derivative beneficiaries. I also understand that my family members may not be considered qualified to apply for refugee resettlement if I, or they, fail to submit DNA evidence upon request.

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LIST OF RELATIONSHIP CODES

CODE

RELATIONSHIP

CODE

RELATIONSHIP

 

 

 

 

AB

ADOPTED BROTHER

GN

GREAT GRANDSON

 

 

 

 

AD

ADOPTED DAUGHTER

GU

GUARDIAN

 

 

 

 

AF

ADOPTED FATHER

HB

HALF BROTHER

 

 

 

 

AM

ADOPTED MOTHER

HS

HALF SISTER

 

 

 

 

AR

ADOPTED SISTER

HU

HUSBAND

 

 

 

 

AS

ADOPTED SON

MC

COUSIN (MALE)

 

 

 

 

AU

AUNT

MR

RELATIVE BY MARRIAGE

 

 

 

 

BH

HUSBAND'S BROTHER

MW

MINOR WIFE

 

 

 

 

BR

BROTHER (BIOLOGICAL)

MO

MOTHER (BIOLOGICAL)

 

 

 

 

DA

DAUGHTER (BIOLOGICAL)

MI

MOTHER-IN-LAW

 

 

 

 

DI

DAUGHTER-IN-LAW

NE

NEPHEW

 

 

 

 

DR

DISTANT RELATIVE

NI

NIECE

 

 

 

 

EH

EX-HUSBAND

NF

UNION WITH FEMALE

 

 

 

 

EW

EX-WIFE

NM

UNION WITH MALE

 

 

 

 

FA

FATHER (BIOLOGICAL)

SI

SISTER (BIOLOGICAL)

 

 

 

 

FI

FATHER-IN-LAW

SO

SON (BIOLOGICAL)

 

 

 

 

FC

COUSIN (FEMALE)

SL

SON-IN-LAW

 

 

 

 

FN

FIANCE(E)

SB

STEP BROTHER

 

 

 

 

FB

FOSTER BROTHER

SD

STEP DAUGHTER

 

 

 

 

FD

FOSTER DAUGHTER

SF

STEP FATHER

 

 

 

 

FF

FOSTER FATHER

SM

STEP MOTHER

 

 

 

 

FM

FOSTER MOTHER

SS

STEP SISTER

 

 

 

 

FT

FOSTER SISTER

SN

STEP SON

 

 

 

 

FS

FOSTER SON

UK

UNKNOWN RELATIONSHIP

 

 

 

 

FR

FRIEND

UM

UNACCOMPANIED MINOR

 

 

 

 

GD

GRANDDAUGHTER

UN

UNCLE

 

 

 

 

GF

GRANDFATHER

UR

UNRELATED

 

 

 

 

GM

GRANDMOTHER

US

HUSBAND'S SISTER

 

 

 

 

GS

GRANDSON

WB

WIFE'S BROTHER

 

 

 

 

GR

GREAT GRANDDAUGHTER

WI

WIFE

 

 

 

 

GH

GREAT GRANDFATHER

WS

WIFE'S SISTER

 

 

 

 

GG

GREAT GRANDMOTHER

 

 

 

 

 

 

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U.S. Department of State

OMB APPROVAL NO.1405-0206

AFFIDAVIT OF RELATIONSHIP

EXPIRES: 07-31-2015

ESTIMATED BURDEN: 60 minutes *

Date Completed (dd mmm yyyy)

Case File ID Number (Alien Number)

Name of National Resettlement Agency

Affiliate ID Number

IMPORTANT NOTICE: By completing this form you are claiming a relationship with family members overseas in order to assist the U.S. Government in determining whether those family members are qualified to apply for admission to the United States under the U.S. Refugee Admissions Program. The AOR itself is not an application on behalf of your family members for admission to the U.S. as a refugee under the U.S. Refugee Admissions Program or a petition for any immigration benefit under U.S. law. Completion of this AOR does not guarantee that your family members will be found qualified to apply for refugee admission or that they ultimately will be admitted to the United States. Additionally, the information listed in this AOR may be used and disclosed by the U.S. Department of State as described in the Privacy Act statement below. The U.S. Government investigates claimed family relationships and verifies the validity of documents. Criminal prosecutions may be sought when family relationships are falsified to obtain immigration benefits.

SECTION I: INFORMATION ABOUT YOU, THE ANCHOR

(a)Your Name (Last, First, Middle)

(b) Your Date of Birth (dd mmm yyyy)

(c) Sex

 

(d) Current Marital Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

 

 

Single

 

 

Married

 

 

 

Divorced

 

 

Separated

 

 

Widow(er)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(e) Current Spouse (Last, First, Middle)

 

 

 

 

 

(f) Your City/Country of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(g) Current U.S. Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(h) Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

 

 

 

 

Work

 

 

 

 

 

 

 

Cellular

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(i) E-mail Address

 

 

 

 

 

 

 

 

 

 

(j) Your Date of Arrival in the U.S. (if refugee) or Date Asylum was Granted (if

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

asylee) (dd mmm yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(k) Your Current U.S. Immigration Status (Check One)

U.S. Citizen - Certificate Number:

Permanent Resident

Asylee

Refugee

Other (Please explain)

(l)If you arrived as a refugee, please complete the following: Your Country of Processing

Your Overseas Case Number, if known

Agency that processed your case overseas, if known

Privacy Act Statement

The U.S. Department of State requests the information on this form, including the agreement of the anchor relative to provide a DNA sample at a later date, to carry out the immigration laws contained in Title 8, United States Code, Section 1157. The U.S. Department of State requests this information to assist in determining whether a family member claimed on this form is qualified to apply for access to the U.S. Refugee Admissions Program (USRAP) for purposes of family reunification. The information you provide may also be disclosed to a) the U.S. Department of Homeland Security for purposes of determining whether your relatives are eligible for admission to the United States and for verifying information provided by the family members listed on this form in any application they may make for admission to the United States under the USRAP or for any other immigration benefit under U.S. law; b) Members of Congress or other Federal, State, and local government agencies having statutory or other lawful authority, as needed for the formulation, amendment, administration, or enforcement of immigration, nationality, and other laws of the United States; and, c) international organizations and resettlement agency partners that work with the USRAP to enable them to coordinate and manage refugee processing overseas and resettlement in the United States. You do not have to complete this form and provide the requested information; however, if you refuse to give some or all of it, your relative's access to the USRAP for refugee resettlement consideration may be denied.

Paperwork Reduction Act

Public reporting burden for this collection of information is estimated to average 60 minutes 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: U.S. Department of State, PRM/A, 2025 E Street, NW Washington DC, 20520. OMB No. 1405-0206.

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Anchor Name (Last, First, Middle)

 

 

 

 

 

 

 

 

 

 

Case File ID Number

 

 

Date of Birth (dd mmm yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II: INFORMATION ABOUT QUALIFYING FAMILY MEMBERS SEEKING ACCESS TO THE USRAP

 

 

 

 

 

 

 

 

A. You may claim only parents, spouse, and unmarried children under age 21 as a Qualifying Family Member

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

Date/Place of

Date/Place of

 

 

 

 

 

 

 

Name

 

 

Sex

(dd mmm yyyy)

 

City/Country

 

 

Nationality

 

Marital

 

Current

Termination of

Relationship

Upload

 

 

 

 

 

 

 

If estimated,

 

 

of Birth

 

 

 

 

 

Status

 

Marriage

Previous

 

to Anchor

Photo

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marriage

 

 

 

 

Last

First

Middle

 

 

 

check box

 

 

 

 

 

 

 

 

 

 

 

 

(dd mmm yyyy)

(dd mmm yyyy)

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

 

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALTERNATE CONTACT ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

 

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For each entry, choose

B. Derivative of Qualifying Family Member in Section II A of this page OR C. Members of the Same Economic Unit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship

 

 

Type

 

 

 

 

 

Sex

 

(dd mmm yyyy)

 

City/Country

 

Nationality

 

Marital

Relationship

to Qualifying

 

Upload

 

 

Name

 

 

 

If estimated,

 

 

of Birth

 

 

Status

to Anchor

 

Family

 

Photo

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member Listed

 

 

 

 

Last

First

Middle

 

 

 

check box

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Above

 

 

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Comments

ADD ADDITIONAL PAGES AS NEEDED FOR EACH ADDITIONAL QUALIFYING FAMILY MEMBER YOU ARE CLAIMING.

DS-7656

Page 2 of 5

Anchor Name (Last, First, Middle)

 

 

 

 

 

 

Case File ID Number

 

Date of Birth (dd mmm yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II A: INFORMATION ABOUT QUALIFYING FAMILY MEMBERS SEEKING ACCESS TO THE USRAP

 

 

 

 

A. You may claim only parents, spouse, and unmarried children under age 21 as a Qualifying Family Member

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

Date/Place of

Date/Place of

 

 

 

 

Name

 

 

Sex

(dd mmm yyyy)

City/Country

 

 

Nationality

Marital

Current

Termination of

Relationship

Upload

 

 

 

 

If estimated,

of Birth

 

 

Status

Marriage

Previous

to Anchor

Photo

 

 

 

 

 

 

 

 

 

Marriage

 

Last

First

Middle

 

 

check box

 

 

 

 

 

 

 

(dd mmm yyyy)

(dd mmm yyyy)

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALTERNATE CONTACT ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For each entry, choose

B. Derivative of Qualifying Family Member in Section II A of this page

OR

C. Members of the Same Economic Unit

 

 

 

 

 

 

Date of Birth

 

 

 

 

Relationship

 

Type

 

 

Sex

(dd mmm yyyy)

 

Nationality

Marital

Relationship

to Qualifying

Upload

Name

 

If estimated,

 

Status

to Anchor

Family

Photo

 

 

 

 

 

Member Listed

Last

First

Middle

 

check box

 

 

 

 

Above

 

2

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

 

 

13

 

 

 

 

 

 

 

 

 

 

14

 

 

 

 

 

 

 

 

 

 

15

 

 

 

 

 

 

 

 

 

 

16

 

 

 

 

 

 

 

 

 

 

17

 

 

 

 

 

 

 

 

 

 

18

 

 

 

 

 

 

 

 

 

 

19

 

 

 

 

 

 

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

Comments

ADD ADDITIONAL PAGES AS NEEDED FOR EACH ADDITIONAL QUALIFYING FAMILY MEMBER YOU ARE CLAIMING.

DS-7656

Page 2a of 5

Anchor Name (Last, First, Middle)

 

 

 

 

 

 

Case File ID Number

 

Date of Birth (dd mmm yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II B: INFORMATION ABOUT QUALIFYING FAMILY MEMBERS SEEKING ACCESS TO THE USRAP

 

 

 

 

A. You may claim only parents, spouse, and unmarried children under age 21 as a Qualifying Family Member

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

Date/Place of

Date/Place of

 

 

 

 

Name

 

 

Sex

(dd mmm yyyy)

City/Country

 

 

Nationality

Marital

Current

Termination of

Relationship

Upload

 

 

 

 

If estimated,

of Birth

 

 

Status

Marriage

Previous

to Anchor

Photo

 

 

 

 

 

 

 

 

 

Marriage

 

Last

First

Middle

 

 

check box

 

 

 

 

 

 

 

(dd mmm yyyy)

(dd mmm yyyy)

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALTERNATE CONTACT ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For each entry, choose

B. Derivative of Qualifying Family Member in Section II A of this page

OR

C. Members of the Same Economic Unit

 

 

 

 

 

 

Date of Birth

 

 

 

 

Relationship

 

Type

 

 

Sex

(dd mmm yyyy)

 

Nationality

Marital

Relationship

to Qualifying

Upload

Name

 

If estimated,

of

Status

to Anchor

Family

Photo

 

 

 

 

Member Listed

Last

First

Middle

 

check box

 

 

 

 

Above

 

2

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

 

 

13

 

 

 

 

 

 

 

 

 

 

14

 

 

 

 

 

 

 

 

 

 

15

 

 

 

 

 

 

 

 

 

 

16

 

 

 

 

 

 

 

 

 

 

17

 

 

 

 

 

 

 

 

 

 

18

 

 

 

 

 

 

 

 

 

 

19

 

 

 

 

 

 

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

ADD ADDITIONAL PAGES AS NEEDED FOR EACH ADDITIONAL QUALIFYING FAMILY MEMBER YOU ARE CLAIMING.

DS-7656

Page 2b of 5

Anchor Name (Last, First, Middle)

 

 

 

 

 

 

Case File ID Number

 

Date of Birth (dd mmm yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II C: INFORMATION ABOUT QUALIFYING FAMILY MEMBERS SEEKING ACCESS TO THE USRAP

 

 

 

 

A. You may claim only parents, spouse, and unmarried children under age 21 as a Qualifying Family Member

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

Date/Place of

Date/Place of

 

 

 

 

Name

 

 

Sex

(dd mmm yyyy)

City/Country

 

 

Nationality

Marital

Current

Termination of

Relationship

Upload

 

 

 

 

If estimated,

of Birth

 

 

Status

Marriage

Previous

to Anchor

Photo

 

 

 

 

 

 

 

 

 

Marriage

 

Last

First

Middle

 

 

check box

 

 

 

 

 

 

 

(dd mmm yyyy)

(dd mmm yyyy)

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALTERNATE CONTACT ADDRESS OF THE QUALIFYING FAMILY MEMBER LISTED ABOVE

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State/Province

 

Postal Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

Cellular Phone Number

 

 

 

 

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For each entry, choose

B. Derivative of Qualifying Family Member in Section II A of this page

OR

. Members of the Same Economic Unit

 

 

 

 

 

 

Date of Birth

 

 

 

 

Relationship

 

Type

 

 

Sex

(dd mmm yyyy)

 

Nationality

Marital

Relationship

to Qualifying

Upload

Name

 

If estimated,

of

Status

to Anchor

Family

Photo

 

 

 

 

Member Listed

Last

First

Middle

 

check box

 

 

 

 

Above

 

2

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

 

 

13

 

 

 

 

 

 

 

 

 

 

14

 

 

 

 

 

 

 

 

 

 

15

 

 

 

 

 

 

 

 

 

 

16

 

 

 

 

 

 

 

 

 

 

17

 

 

 

 

 

 

 

 

 

 

18

 

 

 

 

 

 

 

 

 

 

19

 

 

 

 

 

 

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

ADD ADDITIONAL PAGES AS NEEDED FOR EACH ADDITIONAL QUALIFYING FAMILY MEMBER YOU ARE CLAIMING.

DS-7656

Page 2c of 5

Anchor Name (Last, First, Middle)

Case File ID Number

Date of Birth (dd mmm yyyy)

SECTION III: INFORMATION ABOUT ALL OF YOUR RELATIVE(S) NOT PREVIOUSLY PROVIDED IN SECTION II

In this section please provide information about your parents; adopted parents/stepparents/foster parents; current and former spouses; children (including biological, adopted, step and foster children); and, brothers and sisters (including biological, adopted, step and foster brothers and sisters) if you have NOT previously provided this information under Section II. Please list whether living (L), deceased (D), or unknown (U). If the relative is deceased, please indicate the date of death in the Current or Last Known City/Country column.

(A) PARENTS

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

Date/Place

Date of Marriage

Current or

L,

 

 

 

(dd mmm yyyy)

City/Country

Marital

of Marriage

Termination

 

Name

 

(dd mmm yyyy)

(dd mmm yyyy)

Last Known

D,

 

 

If estimated,

of Birth

Status

 

 

 

If estimated,

If estimated,

City/Country

U

Last

First

Middle

check box

 

 

check box

 

 

check box

 

 

 

 

 

 

 

 

Father

 

 

 

 

 

 

 

 

 

Mother

 

 

 

 

 

 

 

 

 

(B) ADOPTIVE PARENTS/STEPPARENTS/FOSTER PARENTS

 

 

 

 

 

Date of Birth

 

 

Date/Place of Marriage

Date of Marriage

Current or Last

L,

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

(dd mmm yyyy)

City/Country

Marital

(dd mmm yyyy)

Termination

Relationship

 

 

 

 

(dd mmm yyyy)

Known

D,

 

 

 

 

 

If estimated,

of Birth

Status

If estimated,

to Anchor

 

 

 

 

 

If estimated,

City/Country

U

 

 

Last

First

Middle

check box

 

 

check box

check box

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(C) SPOUSES (CURRENT AND FORMER)

 

 

 

 

 

Date of Birth

 

Status

Date/Place of Marriage

Date of Marriage

Current or Last

L,

 

 

 

 

 

 

 

 

 

Name

 

(dd mmm yyyy)

City/Country

(dd mmm yyyy)

Termination

 

 

 

 

(Select

(dd mmm yyyy)

Known

D,

 

 

 

 

 

If estimated,

of Birth

If estimated,

 

 

 

 

 

One)

If estimated,

City/Country

U

 

 

 

 

 

check box

 

check box

 

 

Last

First

Middle

 

 

check box

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

 

 

 

DS-7656

 

 

 

 

 

 

 

Page 3 of 5

Anchor Name (Last, First, Middle)

Case File ID Number

Date of Birth (dd mmm yyyy)

SECTION III: INFORMATION ABOUT ALL OF YOUR RELATIVES NOT PREVIOUSLY PROVIDED IN SECTION II (Continued)

In this section please provide information for your parents and stepparents; current and former spouses; children; and, brothers and sisters if you have not previously provided this information under Section II. Please list whether living (L), deceased (D), or unknown (U). If the relative is deceased, please indicate the date of death in the Current or Last Known City/Country column.

For children and brothers/sisters, please list from oldest to youngest.

(D)CHILDREN (Biological, Adopted, Step and Foster Children) (PLEASE LIST OLDEST TO YOUNGEST)

 

 

 

Date of Birth

 

 

 

L,

 

 

 

 

(dd mmm yyyy)

City/Country

Marital

Current or Last

Relationship

 

 

Sex

D,

 

Name

If estimated,

of Birth

Status

Known City/Country

to Anchor

 

 

U

 

 

 

check box

 

 

 

 

Last

First

Middle

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

13

 

 

 

 

 

 

 

 

14

 

 

 

 

 

 

 

 

15

 

 

 

 

 

 

 

 

(E) BROTHERS AND SISTERS (Biological, Adopted, Step and Foster Brothers/Sisters) (PLEASE LIST OLDEST TO YOUNGEST)

 

 

 

Date of Birth

 

 

 

L,

 

 

 

 

(dd mmm yyyy)

 

Marital

Current or Last

Relationship

 

 

Sex

City/Country of Birth

D,

 

Name

If estimated,

Status

Known City/Country

to Anchor

 

 

 

U

 

 

 

check box

 

 

 

 

Last

First

Middle

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

5

 

 

 

 

 

 

 

 

6

 

 

 

 

 

 

 

 

7

 

 

 

 

 

 

 

 

8

 

 

 

 

 

 

 

 

9

 

 

 

 

 

 

 

 

10

 

 

 

 

 

 

 

 

11

 

 

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

13

 

 

 

 

 

 

 

 

14

 

 

 

 

 

 

 

 

15

 

 

 

 

 

 

 

 

DS-7656

 

 

 

 

 

 

 

Page 4 of 5

Anchor Name (Last, First, Middle)

Case File ID Number

Date of Birth (dd mmm yyyy)

SECTION IV: ADDITIONS/EXPLANATIONS

Identify for which section, number and name the information is being provided.

SECTION V: SIGNATURES

I certify, under penalty of perjury under the laws of the United States of America, that all of the foregoing information given in this affidavit is true and correct to the best of my knowledge. I understand that the information listed in this Affidavit of Relationship may be used by the U.S. Department of State or the U.S. Department of Homeland Security in the manner described in the Privacy Act statement.

By submitting this Affidavit of Relationship I understand that I and certain Qualifying Family Members (parents, spouse, unmarried children under age

21)will be requested to submit DNA evidence to verify our claimed family relationships. I agree that I will submit DNA evidence at such time it is requested, and I agree to pay all necessary fees associated with that expense and the expenses associated with the submittal of DNA evidence by any of the Qualifying Family Members I am claiming on this form. I further understand that DNA testing may be requested between my Qualifying Family Member(s) and their derivative beneficiaries at no expense to the U.S. Government. I also understand that my family members may not be considered qualified to apply for refugee resettlement if I, or they, fail to submit DNA evidence upon request.

Your Signature

Print Name

Date (dd mmm yyyy)

NAME AND SIGNATURE OF PERSON WHO ASSISTED IN PREPARING THIS FORM

I affirm that I assisted the anchor listed above in completing this form and that the federal or state agency.

listed above provided valid identification issued by a U.S.

Signature

Print Full

Date (dd mmm yyyy)

Affiliate Name and Address

Phone Number

DS-7656

Page 5 of 5

Anchor Name (Last, First, Middle)

Case File ID Number

Date of Birth (dd mmm yyyy)

 

 

 

IMAGES - Section II

QUALIFYING FAMILY MEMBER

Name

 

DOB

Rel To Anch

Name

 

DOB

Rel To QFM

Name

 

 

Name

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

DS-7656

Photo Page 1 of 4

Anchor Name (Last, First, Middle)

Case File ID Number

Date of Birth (dd mmm yyyy)

 

 

 

IMAGES - Section II A

QUALIFYING FAMILY MEMBER

Name

 

DOB

Rel To Anch

Name

 

DOB

Rel To QFM

Name

 

 

Name

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

DS-7656

Photo Page 2 of 4

Anchor Name (Last, First, Middle)

Case File ID Number

Date of Birth (dd mmm yyyy)

 

 

 

IMAGES - Section II B

QUALIFYING FAMILY MEMBER

Name

 

DOB

Rel To Anch

Name

 

DOB

Rel To QFM

Name

 

 

Name

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

DS-7656

Photo Page 3 of 4

Anchor Name (Last, First, Middle)

Case File ID Number

Date of Birth (dd mmm yyyy)

 

 

 

IMAGES - Section II C

QUALIFYING FAMILY MEMBER

Name

 

DOB

Rel To Anch

Name

 

DOB

Rel To QFM

Name

 

 

Name

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

Name

 

 

Name

 

 

Name

 

 

 

 

 

 

 

 

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

DOB

Rel To QFM

 

 

 

 

 

 

 

 

DS-7656

Photo Page 4 of 4