Rescission Details

Form I 485 is an application used to apply for permanent residence in the United States. This form can be used by individuals who are already in the United States or those who are outside of the country. There are certain requirements that must be met in order to qualify for permanent residency, and this form will help you determine if you meet those requirements. The process of applying for permanent residency can be complex, so it is important to understand what is involved. By using Form I 485, you can begin the process of becoming a permanent resident of the United States.

Listed below are some specifics of form i 485. This page can provide specifics of the form's size, completion time, and the blanks you may be needed to fill.

QuestionAnswer
Form NameForm I 485
Form Length18 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 30 sec
Other namesForm G-1145, Report of Medical Examination and Vaccination ...G-325A, Biographic Information - USCIS

Form Preview Example

 

 

 

 

 

 

Application to Register Permanent Residence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Adjust Status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USCIS

 

 

 

 

 

 

 

 

Department of Homeland Security

 

 

 

 

 

 

 

 

 

 

 

 

 

Form I-485

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OMB No. 1615-0023

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizenship and Immigration Services

 

 

 

 

 

 

Expires 09/30/2021

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For USCIS Use Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preference Category:

 

 

 

 

 

 

 

 

Receipt

 

 

 

 

 

 

 

Action Block

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country Chargeable:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Priority Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Form I-693 Received:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant

Interview

 

 

 

Section of Law

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Interviewed

Waived

 

 

INA 209(a)

 

 

 

INA 249

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of

 

 

 

 

INA 209(b)

 

 

 

Sec. 13, Act of 9/11/57

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Initial Interview:

 

 

 

 

 

INA 245(a)

 

 

 

Cuban Adjustment Act

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lawful Permanent

 

 

 

 

INA 245(i)

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Resident as of:

 

 

 

 

 

INA 245(m)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To be completed by an attorney or accredited representative (if any).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Select this box if

 

Volag Number

 

 

 

Attorney State Bar Number

 

Attorney or Accredited Representative

 

Form G-28 is

 

 

(if any)

 

 

 

(if applicable)

 

USCIS Online Account Number (if any)

 

attached.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

► START HERE - Type or print in black ink.

 

 

 

 

A-Number A-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, U.S. Citizenship and Immigration Services (USCIS) may deny your application.

Part 1. Information About You (Person applying

for lawful permanent residence)

Your Current Legal Name (do not provide a

nickname)

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

3.a. Family Name (Last Name)

3.b. Given Name (First Name)

3.c. Middle Name

4.a. Family Name (Last Name)

4.b. Given Name (First Name)

4.c. Middle Name

Other Names You Have Used Since Birth (if

applicable)

NOTE: Provide all other names you have ever used, including your family name at birth, other legal names, nicknames, aliases, and assumed names. If you need extra space to complete this section, use the space provided in Part 14. Additional Information.

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

Other Information About You

5. Date of Birth (mm/dd/yyyy)

NOTE: In addition to providing your actual date of birth, include any other dates of birth you have used in connection with any legal names or non-legal names in the space provided in Part 14. Additional Information.

6.

Sex

Male

Female

7.City or Town of Birth

Form I-485 Edition 03/10/21

Page 1 of 18

A-Number A-

Part 1. Information About You (Person applying

for lawful permanent residence) (continued)

8.Country of Birth

9.Country of Citizenship or Nationality

10.Alien Registration Number (A-Number) (if any)

A-

NOTE: If you have EVER used other A-Numbers, include the additional A-Numbers in the space provided in Part 14. Additional Information.

11.USCIS Online Account Number (if any)

12.U.S. Social Security Number (if any)

Recent Immigration History

Provide the information for Item Numbers 15. - 19. if you last entered the United States using a passport or travel document.

15.Passport Number Used at Last Arrival

16.Travel Document Number Used at Last Arrival

17.Expiration Date of this Passport or Travel Document

(mm/dd/yyyy)

18.Country that Issued this Passport or Travel Document

19.Nonimmigrant Visa Number from this Passport (if any)

Place of Last Arrival into the United States

20.a. City or Town

U.S. Mailing Address

13.a. In Care Of Name (if any)

13.b. Street Number

and Name

13.c. Apt. Ste. Flr.

13.d. City or Town

13.e. State

 

13.f. ZIP Code

 

 

 

Alternate and/or Safe Mailing Address

If you are applying based on the Violence Against Women Act (VAWA) or as a special immigrant juvenile, human trafficking victim (T nonimmigrant), or victim of a qualifying crime (U nonimmigrant) and you do not want USCIS to send notices about this application to your home, you may provide an alternative and/or safe mailing address.

14.a. In Care Of Name (if any)

14.b. Street Number

and Name

14.c.

Apt.

Ste.

Flr.

 

 

14.d.

City or Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.e.

State

 

 

14.f.

ZIP Code

 

 

 

 

 

 

 

 

 

20.b. State

21. Date of Last Arrival (mm/dd/yyyy)

When I last arrived in the United States, I:

22.a. Was inspected at a port of entry and admitted as (for example, exchange visitor; visitor, waived through; temporary worker; student):

22.b. Was inspected at a port of entry and paroled as (for example, humanitarian parole, Cuban parole):

22.c. Came into the United States without admission or parole.

22.d. Other:

If you were issued a Form I-94 Arrival-Departure Record Number:

23.a. Form I-94 Arrival-Departure Record Number

23.b. Expiration Date of Authorized Stay Shown on Form I-94

(mm/dd/yyyy)

23.c. Status on Form I-94 (for example, class of admission, or paroled, if paroled)

Form I-485 Edition 03/10/21

Page 2 of 18

A-Number A-

Part 1. Information About You (Person applying

for lawful permanent residence) (continued)

24.What is your current immigration status (if it has changed since your arrival)?

Provide your name exactly as it appears on your Form I-94 (if any)

25.a. Family Name

(Last Name)

25.b. Given Name

(First Name)

25.c. Middle Name

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

Other relative of a U.S. citizen or relative of a lawful permanent resident under the family-based preference categories, 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

VAWA self-petitioner, 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

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

1.b. Employment-based

Alien worker, Form I-140

Alien entrepreneur, Form I-526

1.c. Special Immigrant

Religious worker, Form I-360

Special immigrant juvenile, Form I-360

Certain Afghan or Iraqi national, Form I-360

Certain international broadcaster, Form I-360

Certain G-4 international organization or family member or NATO-6 employee or family member, Form I-360

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.

Form I-485 Edition 03/10/21

Page 3 of 18

A-Number A-

Part 2. Application Type or Filing Category

(continued)

Information About Your Immigrant Category

If you are the principal applicant, provide the following information.

3.Receipt Number of Underlying Petition (if any)

4.Priority Date from Underlying Petition (if any)

(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)

A-

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)

3.Decision (for example, approved, refused, denied, withdrawn)

4.Date of Decision (mm/dd/yyyy)

Address History

Provide physical addresses for everywhere you have lived during the last five years, whether inside or outside the United States. Provide your current address first. If you need extra space to complete this section, use the space provided in Part 14. Additional Information.

Physical Address 1 (current address)

5.a. Street Number

and Name

5.b. Apt. Ste. Flr.

5.c. City or Town

5.d. State

 

5.e. ZIP Code

 

 

 

5.f. Province

5.g. Postal Code

5.h. Country

Dates of Residence

6.a. From (mm/dd/yyyy)

6.b. To (mm/dd/yyyy)

PRESENT

 

 

 

 

Physical Address 2

Part 3. Additional Information About You

1.Have you ever applied for an immigrant visa to obtain permanent resident status at a U.S. Embassy or U.S.

Consulate abroad?

Yes

No

 

7.a. Street Number

and Name

7.b. Apt. Ste. Flr.

7.c. City or Town

If you answered "Yes" to Item Number 1., complete Item Numbers 2.a. - 4. below. If you need extra space to complete this section, use the space provided in Part 14. Additional Information.

Location of U.S. Embassy or U.S. Consulate

2.a. City

2.b. Country

7.d. State

7.f. Province

7.g. Postal Code

7.h. Country

7.e. ZIP Code

Form I-485 Edition 03/10/21

Page 4 of 18

A-Number A-

Part 3. Additional Information About You

(continued)

Dates of Residence

8.a. From (mm/dd/yyyy)

8.b. To (mm/dd/yyyy)

Provide your most recent address outside the United States where you lived for more than one year (if not already listed above).

9.a. Street Number

and Name

9.b. Apt. Ste. Flr.

9.c. City or Town

9.d. State

 

9.e. ZIP Code

 

 

 

9.f. Province

9.g. Postal Code

9.h. Country

Dates of Residence

10.a. From (mm/dd/yyyy)

10.b. To (mm/dd/yyyy)

Employment History

Provide your employment history for the last five years, whether inside or outside the United States. Provide the most recent employment first. If you need extra space to complete this section, use the space provided in Part 14. Additional Information.

Employer 1 (current or most recent)

11.Name of Employer or Company

Address of Employer or Company

12.a. Street Number

and Name

12.b.

Apt.

Ste.

Flr.

 

 

12.c.

City or Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.d.

State

 

 

12.e. ZIP Code

 

 

 

 

 

 

 

 

 

12.f.

Province

 

 

 

 

 

 

 

 

 

 

12.g.

Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.h.

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.Your Occupation

Dates of Employment

14.a. From (mm/dd/yyyy)

14.b. To (mm/dd/yyyy)

Employer 2

15.Name of Employer or Company

Address of Employer or Company

16.a. Street Number

and Name

16.b.

Apt.

Ste.

Flr.

 

 

16.c.

City or Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.d.

State

 

 

16.e. ZIP Code

 

 

 

 

 

 

 

 

 

16.f.

Province

 

 

 

 

 

 

 

 

 

 

16.g.

Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.h.

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.Your Occupation

Dates of Employment

18.a. From (mm/dd/yyyy)

18.b. To (mm/dd/yyyy)

Form I-485 Edition 03/10/21

Page 5 of 18

A-Number A-

Part 3. Additional Information About You

(continued)

Provide your most recent employment outside of the United States (if not already listed above).

19.Name of Employer or Company

Address of Employer or Company

20.a. Street Number

and Name

20.b.

Apt.

Ste.

Flr.

 

20.c.

City or Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.Date of Birth (mm/dd/yyyy)

4.

Sex

Male

Female

5.City or Town of Birth

6.Country of Birth

7.Current City or Town of Residence (if living)

8.Current Country of Residence (if living)

20.d. State

20.f. Province

20.g. Postal Code 20.h. Country

20.e. ZIP Code

Information About Your Parent 2

Parent 2's Legal Name

9.a. Family Name

(Last Name)

9.b. Given Name

(First Name)

9.c. Middle Name

21.Your Occupation

Dates of Employment

22.a. From (mm/dd/yyyy)

22.b. To (mm/dd/yyyy)

Part 4. Information About Your Parents

Information About Your Parent 1

Parent 1's Legal Name

Parent 2's Name at Birth (if different than above)

10.a. Family Name

(Last Name)

10.b. Given Name

(First Name)

10.c. Middle Name

11.Date of Birth (mm/dd/yyyy)

12. Sex

Male

Female

13.City or Town of Birth

1.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name

14.Country of Birth

15.Current City or Town of Residence (if living)

Parent 1's Name at Birth (if different than above)

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

16.Current Country of Residence (if living)

Form I-485 Edition 03/10/21

Page 6 of 18

A-Number A-

Part 5. Information About Your Marital History

1.What is your current marital status?

Single, Never Married Married Divorced

Widowed Marriage Annulled

Legally Separated

2.If you are married, is your spouse a current member of the U.S. armed forces or U.S. Coast Guard?

Place of Marriage to Current Spouse 9.a. City or Town

9.b. State or Province

9.c. Country

N/A Yes No

3.How many times have you been married (including annulled marriages and marriages to the same person)?

10.Is your current spouse applying with you?

Yes

No

Information About Your Current Marriage

(including if you are legally separated)

If you are currently married, provide the following information about your current spouse.

Current Spouse's Legal Name

4.a. Family Name

(Last Name)

4.b. Given Name

(First Name)

4.c. Middle Name

5.A-Number (if any)

A-

6.Current Spouse's Date of Birth (mm/dd/yyyy)

7.Date of Marriage to Current Spouse (mm/dd/yyyy)

Current Spouse's Place of Birth

8.a. City or Town

8.b. State or Province

8.c. Country

Information About Prior Marriages (if any)

If you have been married before, whether in the United States or in any other country, provide the following information about your prior spouse. If you have had more than one previous marriage, use the space provided in Part 14. Additional Information to provide the information below.

Prior Spouse's Legal Name (provide family name before marriage)

11.a. Family Name

(Last Name)

11.b. Given Name

(First Name)

11.c. Middle Name

12.Prior Spouse's Date of Birth (mm/dd/yyyy)

13.Date of Marriage to Prior Spouse (mm/dd/yyyy)

Place of Marriage to Prior Spouse

14.a. City or Town

14.b. State or Province

14.c. Country

15.Date Marriage with Prior Spouse Legally Ended

(mm/dd/yyyy)

Form I-485 Edition 03/10/21

Page 7 of 18

A-Number A-

Part 5. Information About Your Marital History

(continued)

Place Where Marriage with Prior Spouse Legally Ended 16.a. City or Town

16.b. State or Province

Child 2

Current Legal Name

7.a. Family Name (Last Name)

7.b. Given Name (First Name)

7.c. Middle Name

8.A-Number (if any)

16.c. Country

Part 6. Information About Your Children

1.Indicate the total number of ALL living children (including adult sons and daughters) that you have.

NOTE: The term “children” includes all biological or legally adopted children, as well as current stepchildren, of any age, whether born in the United States or other countries, married or unmarried, living with you or elsewhere and includes any missing children and those born to you outside of marriage.

Provide the following information for each of your children. If you have more than three children, use the space provided in Part 14. Additional Information.

Child 1

Current Legal Name

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

3.A-Number (if any)

A-

4. Date of Birth (mm/dd/yyyy)

5.Country of Birth

6.

Is this child applying with you?

Yes

No

 

 

 

 

A-

9.Date of Birth (mm/dd/yyyy)

10.Country of Birth

11. Is this child applying with you?

Yes

No

Child 3

Current Legal Name

12.a. Family Name

(Last Name)

12.b. Given Name

(First Name)

12.c. Middle Name

13.A-Number (if any)

A-

14.Date of Birth (mm/dd/yyyy)

15.Country of Birth

16. Is this child applying with you?

Yes

No

Part 7. Biographic Information

1.Ethnicity (Select only one box)

Hispanic or Latino

Not Hispanic or Latino

2.Race (Select all applicable boxes)

White

Asian

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Form I-485 Edition 03/10/21

Page 8 of 18

A-Number A-

Part 7. Biographic Information (continued)

Dates of Membership or Dates of Involvement

3.

Height

Feet

4.Weight

5.Eye Color (Select only one box)

Black

Blue

Gray

Green

Maroon

Pink

6.Hair Color (Select only one box)

Bald (No hair)

Black

Brown

Gray

Sandy

White

Inches

Pounds

Brown

Hazel Unknown/Other

Blond

Red Unknown/Other

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

Part 8. General Eligibility and Inadmissibility Grounds

8.Nature of Group

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 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)

Form I-485 Edition 03/10/21

Page 9 of 18

A-Number A-

Part 8. General Eligibility and Inadmissibility

Grounds (continued)

Answer Item Numbers 14. - 80.b. Choose the answer that you think is correct. If you answer “Yes” to any questions (or if you answer "No," but are unsure of your answer), provide an explanation of the events and circumstances in the space provided in Part 14. Additional Information.

14.Have you EVER been denied admission to the United

States?

Yes

No

 

15.Have you EVER been denied a visa to the United States?

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

 

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

 

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

Form I-485 Edition 03/10/21

Page 10 of 18

A-Number A-

Part 8. General Eligibility and Inadmissibility

Grounds (continued)

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

 

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

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

 

Form I-485 Edition 03/10/21

Page 11 of 18

A-Number A-

Part 8. General Eligibility and Inadmissibility

Grounds (continued)

Have you EVER:

48.a. Committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use of a weapon or explosive to harm another individual or cause

substantial damage to property?

Yes

No

 

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.?

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

 

49.Have you EVER received any type of military,

paramilitary, or weapons training?

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

 

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

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

 

Form I-485 Edition 03/10/21

Page 12 of 18

A-Number A-

Part 8. General Eligibility and Inadmissibility

Grounds (continued)

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 Assistance

61.Have you received public assistance in the United States from any source, including the U.S. Government or any state, county, city, or municipality (other than emergency

medical treatment)?

Yes

No

 

62.Are you likely to receive public assistance in the future in the United States from any source, including the U.S. Government or any state, county, city, or municipality (other than emergency medical treatment)?

Yes No

Illegal Entries and Other Immigration Violations

63.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

 

63.b. If your answer to Item Number 63.a. is "Yes," do you

believe you had reasonable cause?

Yes

No

 

63.c. If your answer to Item Number 63.b. is "Yes," attach a written statement explaining why you had reasonable cause.

64.Have you EVER submitted fraudulent or counterfeit documentation to any U.S. Government official to obtain or attempt to obtain any immigration benefit, including a

visa or entry into the United States?

Yes

No

 

65.Have you EVER lied about, concealed, or misrepresented any information on an application or petition to obtain a visa, other documentation required for entry into the United States, admission to the United States, or any other

kind of immigration benefit?

Yes

No

 

66.Have you EVER falsely claimed to be a U.S. citizen (in

writing or any other way)?

Yes

No

 

67.Have you EVER been a stowaway on a vessel or aircraft

arriving in the United States?

Yes

No

 

68.Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or to try to enter the United States illegally (alien smuggling)?

Yes No

69.Are you under a final order of civil penalty for violating INA section 274C for use of fraudulent documents?

Yes No

Removal, Unlawful Presence, or Illegal Reentry After Previous Immigration Violations

70.Have you EVER been excluded, deported, or removed from the United States or have you ever departed the United States on your own after having been ordered excluded, deported, or removed from the United States?

Yes No

71.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:

72.a. For more than 180 days but less than a year, and then

 

departed the United States?

Yes

No

 

72.b. For one year or more and then departed the United States?

Yes No

NOTE: You were unlawfully present in the United States if you entered the United States without being inspected and admitted or inspected and paroled, or if you legally entered the United States but you stayed longer than permitted.

Form I-485 Edition 03/10/21

Page 13 of 18

A-Number A-

Part 8. General Eligibility and Inadmissibility

Grounds (continued)

Since April 1, 1997, have you EVER reentered or attempted to reenter the United States without being inspected and admitted or paroled after:

73.a. Having been unlawfully present in the United States for

more than one year in the aggregate?

Yes

No

 

73.b. Having been deported, excluded, or removed from the

United States?

Yes

No

 

80.a. Have you EVER left or remained outside the United States to avoid or evade training or service in the U.S. armed forces in time of war or a period declared by the

President to be a national emergency?

Yes

No

 

80.b. If your answer to Item Number 80.a. is “Yes,” what was your nationality or immigration status immediately before you left (for example, U.S. citizen or national, lawful permanent resident, nonimmigrant, parolee, present without admission or parole, or any other status)?

Miscellaneous Conduct

74.Do you plan to practice polygamy in the United States?

Yes No

75.Are you accompanying another foreign national who requires your protection or guardianship but who is inadmissible after being certified by a medical officer as being helpless from sickness, physical or mental disability, or infancy, as described in INA section 232(c)?

Yes No

76.Have you EVER assisted in detaining, retaining, or withholding custody of a U.S. citizen child outside the United States from a U.S. citizen who has been granted

custody of the child?

Yes

No

 

77.Have you EVER voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or

regulation in the United States?

Yes

No

 

78.Have you EVER renounced U.S. citizenship to avoid

being taxed by the United States?

Yes

No

 

Have you EVER:

79.a. Applied for exemption or discharge from training or service in the U.S. armed forces or in the U.S. National

Security Training Corps on the ground that you are a

 

foreign national?

Yes

No

 

79.b. Been relieved or discharged from such training or service on the ground that you are a foreign national?

Yes No

79.c. Been convicted of desertion from the U.S. armed forces?

Yes No

Part 9. Accommodations for Individuals With Disabilities and/or Impairments

NOTE: Read the information in the Form I-485 Instructions before completing this part.

1.Are you requesting an accommodation because of your

disabilities and/or impairments?

Yes

No

 

If you answered "Yes" to Item Number 1., select any applicable box in Item Numbers 2.a. - 2.c. and provide an answer.

2.a. I am deaf or hard of hearing and request the following accommodation. (If you are requesting a sign-language interpreter, indicate for which language (for example, American Sign Language).):

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

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

Form I-485 Edition 03/10/21

Page 14 of 18

A-Number A-

Part 10. Applicant's Statement, Contact

Information, Declaration, Certification, and

Signature

NOTE: Read the Penalties section of the Form I-485 Instructions before completing this part. You must file Form I-485 while in the United States.

Applicant's Statement

NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.

1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question.

1.b. The interpreter named in Part 11. read to me every question and instruction on this application and my answer to every question in

,

I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

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

1)I reviewed and understood all of the information contained in, and submitted with, my application; and

2)All of this information was complete, true, and correct at the time of filing.

I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct.

2.

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

At my request, the preparer named in Part 12.,

,

Applicant's Signature

6.a. Applicant's Signature (sign in ink)

prepared this application for me based only upon

6.b.

Date of Signature (mm/dd/yyyy)

 

information I provided or authorized.

NOTE TO ALL APPLICANTS: If you do not completely fill

Applicant's Contact Informationout this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.

3.Applicant's Daytime Telephone Number

4.Applicant's Mobile Telephone Number (if any)

5.Applicant's Email Address (if any)

Applicant's Declaration and Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek.

I understand that if I am a male who is 18 to 26 years of age, submitting this application will automatically register me with the Selective Service System as required by the Military Selective Service Act.

Part 11. Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

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

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

2.Interpreter's Business or Organization Name (if any)

Form I-485 Edition 03/10/21

Page 15 of 18

A-Number A-

Part 11. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State

 

3.e. ZIP Code

 

 

 

3.f. Province

3.g. Postal Code

3.h. Country

Interpreter's Contact Information

4.Interpreter's Daytime Telephone Number

5.Interpreter's Mobile Telephone Number (if any)

6.Interpreter's Email Address (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:

 

I am fluent in English and

,

which is the same language specified in Part 10., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Declaration and Certification, and has verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature (sign in ink)

7.b. Date of Signature (mm/dd/yyyy)

Part 12. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

Provide the following information about the preparer.

Preparer's Full Name

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

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

2.Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State

 

3.e. ZIP Code

 

 

 

3.f. Province

3.g. Postal Code

3.h. Country

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

5.Preparer's Mobile Telephone Number (if any)

6.Preparer's Email Address (if any)

Form I-485 Edition 03/10/21

Page 16 of 18

A-Number A-

Part 12. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

(continued)

Preparer's Statement

7.a.

I am not an attorney or accredited representative

 

but have prepared this application on behalf of

 

the applicant and with the applicant's consent.

7.b.

I am an attorney or accredited representative and

 

my representation of the applicant in this case

 

extends

does not extend beyond the

 

preparation of this application.

NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.

NOTE: Do not complete Part 13. until the USCIS Officer instructs you to do so at the interview.

Part 13. Signature at Interview

I swear (affirm) and certify under penalty of perjury under the laws of the United States of America that I know that the contents of this Form I-485, Application to Register Permanent Residence or Adjust Status, subscribed by me, including the

corrections made to this application, numbered

through

 

, are complete, true, and correct. All

 

 

 

additional pages submitted by me with this Form I-485, on

numbered pages

 

through

 

are complete,

 

 

 

 

 

true, and correct. All documents submitted at this interview were provided by me and are complete, true, and correct.

Subscribed to and sworn to (affirmed) before me

USCIS Officer's Printed Name or Stamp

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use.

Date of Signature (mm/dd/yyyy)

Applicant's Signature (sign in ink)

USCIS Officer's Signature (sign in ink)

Preparer's Signature

8.a. Preparer's Signature (sign in ink)

8.b. Date of Signature (mm/dd/yyyy)

Form I-485 Edition 03/10/21

Page 17 of 18

A-Number A-

Part 14. Additional Information

If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

2. A-Number (if any) A-

3.a. Page Number 3.b. Part Number 3.c. Item Number

5.a. Page Number 5.b. Part Number 5.c. Item Number

5.d.

6.a. Page Number 6.b. Part Number 6.c. Item Number

6.d.

3.d.

7.a. Page Number 7.b. Part Number 7.c. Item Number

7.d.

4.a. Page Number 4.b. Part Number 4.c. Item Number

4.d.

Form I-485 Edition 03/10/21

Page 18 of 18

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