Form I 643 – Fill Out and Use This PDF

The Form I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status, is a critical document for individuals seeking to adjust their status in the United States after being granted asylum or refugee status. Managed by the Department of Homeland Security and the U.S. Citizenship and Immigration Services, this form collects comprehensive personal, educational, and employment information to help authorities make informed decisions. For those looking to complete their adjustment of status process, it's essential to accurately fill out and submit this form. Click the button below to start filling out your I-643 form.

Get Form Now Download PDF

Form I 643 PDF Details

Embarking on the path to a new life in the United States carries a profound significance for refugees and asylees, a journey marked with steps both big and small toward establishing their place in a new society. Among these steps, filling out official documents plays a crucial role, with the I-643 form being a prime example. The I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status, is designed by the U.S. Citizenship and Immigration Services under the Department of Homeland Security. This form serves multiple purposes: it collects vital statistical data for health and human services, aids in the adjustment of status for refugees and asylees, and encapsulates an individual's journey – from personal and demographic information to employment history, education, language skills, and even public assistance received. By requiring details like name, birthplace, current address, family details, and previous residences in the United States, the form paints a comprehensive picture of the applicant’s background. Additionally, it delves into the applicant's education and employment both prior to and after arriving in the United States, their proficiency in English, and any public assistance they have utilized. Thus, the I-643 form stands as a critical document for those adjusting to a new life, reflecting a blend of legal processes and the human experience behind each application.

Question	Answer
Form Name	Form I 643
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	i 643 statical data about us citizenship form

Form Preview Example

OMB No: 1615-0070; Expires 01/31/2015

Department of Homeland Security

U.S. Citizenship and Immigration Services

I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status

Print or type in blue or black ink.

Name:

Last (Family)

First (Given)

Middle

Today's Date: (mm/dd/yyyy)

Alien Registration Number:

A -

Country of Birth:

Country of Citizenship/Nationality:

Social Security Number:

Native Language:

Date of Birth (mm/dd/yyyy)

Telephone Number (with area code)

Cellphone Number (with area code)

Current Address:

(Number, Street, and Apartment No.)

(City)

(State)

(Zip Code)

My three most recent cities of residence in the United States have been:

(List most recent first)

City or Town

State

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Present

There are

members of the household,

of whom are employed.

(Please use another sheet(s) if needed)

Name

Relationship

Gender

Date of Birth

Country of

Alien Number

Currently Employed?

Attending School?

to Me

M/F

(mm/dd/yyyy)

Birth

Yes

(Self)

4. My employment since entering the United States has been:				(List most recent first)			Check One
	Company Name	Location	From	To	Job Title	Wage Per	Part	Full
	Company Name	City, State	(mm/dd/yyyy)	(mm/dd/yyyy)	Job Title	Hour	Time	Time
		City, State	(mm/dd/yyyy)	(mm/dd/yyyy)		Hour	Time	Time

My major occupation or profession before coming to the United States was:

5.	My education before coming to the United States was:				(Check all that apply)
	Grades 1-8		Some university			My knowledge of English was acquired by: (Check all that apply)
	Some high school		University diploma			Training in the U.S.			Use in another country
	High school diploma		Graduate studies			Use in the U.S.			Training in refugee camp
	Technical school		Professional training			Training in another country			Other (Please explain):
	Technical school certificate		Graduate degree
6.	I have had the following training or education in the U.S.				(Check all that apply)		7. English Language Skills:			(Check one)
Type of Training/Education		Course of Study		Check If		Check If	Speaking	None	A Few Words	Fair
Type of Training/Education		Course of Study		Still Attending		Completed		Good
				Still Attending		Completed
	High School						Reading
	High School							None	A Few Words	Fair
	College							None	A Few Words	Fair
	College							Good
	Technical/Vocational						Writing	Good
	Technical/Vocational						Writing	None	A Few Words	Fair
	Other (specify):							Good

8.Since in the United States, list as many types of public assistance (excluding emergency medical treatment) that you have received or someone has received on your behalf. Please include public assistance received from the U.S. Government or any State, county, city, or municipality.

Public Assistance	From (mm/yyyy)	To (mm/yyyy)	Public Assistance	From (mm/yyyy)	To (mm/yyyy)

Cash assistance (Welfare)			Medical assistance

Food Stamps			Other (specify):

SSI

Form I-643 (01/08/13) Y Page 1

Form I 643 – Fill Out and Use This PDF

Form I 643 PDF Details

Form Preview Example

Form I 643 isn’t the one you’re looking for?

Related Documents