Form I 643 – Fill Out and Use This PDF

Form I 643 isn't just a regular piece of paperwork. It is an official, legally binding form from the United States Citizenship and Immigration Services (USCIS) for choosing to forgo travel document conventions or statutory limitations on expatriation or revocation. This form consist of a considerable amount of legal verbiage inputting the declarant's immigration status, country of origin information, past immigration details, and more. Before signing this document, the declarant must carefully read through its various disclosure statements, ensuring that the information provided is current and valid; otherwise it handicaps their chance to successfully move forward with immigration policy changes.

Form I 643 PDF Details

If you're a U.S. citizen or resident and plan to work abroad, you'll need to file Form I-643 with the U.S. Department of State before your departure. This form is used to certify that you have been vaccinated against certain diseases, such as yellow fever and typhoid fever, that are found in many parts of the world. Failing to submit this form may result in denied entry into certain countries. Make sure to fill out the form accurately and completely so that there are no issues when you arrive at your destination.

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

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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

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