Form I 90 – Fill Out and Use

Part 1. Information About You

1.Alien Registration Number (A-Number)

A-

2.USCIS Online Account Number (if any)

►

Your Full Name

NOTE: Your card will be issued in this name.

Mailing Address

6.a. In Care Of Name

6.b. Street Number

and Name

6.c. Apt. Ste. Flr.

6.d. City or Town

3.a. Family Name

(Last Name)

3.b. Given Name

(First Name)

3.c. Middle Name

4.Has your name legally changed since the issuance of your Permanent Resident Card?

6.e. State

6.g. Province

6.h. Postal Code 6.i. Country

6.f. ZIP Code

Yes (Proceed to Item Numbers 5.a. - 5.c.)

No (Proceed to Item Numbers 6.a. - 6.i.)

N/A - I never received my previous card. (Proceed to Item Numbers 6.a. - 6.i.)

Provide your name exactly as it is printed on your current Permanent Resident Card.

NOTE: Attach all evidence of your legal name change with this application.

5.a. Family Name

(Last Name)

5.b. Given Name

(First Name)

5.c. Middle Name

Physical Address

Provide this information only if different than mailing address.

7.a. Street Number

and Name

7.b. Apt. Ste. Flr.

7.c. City or Town

7.f. Province

7.g. Postal Code

7.h. Country

Part 1. Information About You (continued)

Additional Information

10.City/Town/Village of Birth

11.Country of Birth

Mother's Name

12.Given Name (First Name)

Father's Name

13.Given Name (First Name)

14.Class of Admission

15.Date of Admission

(mm/dd/yyyy)

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

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Part 2. Application Type

NOTE: If your conditional permanent resident status (for

example: CR1, CR2, CF1, CF2) is expiring within the next 90 days, then do not file this application. (See the What is the Purpose of This Application section of the Form I-90 Instructions for further information.)

My status is (Select only one box):

1.a.

1.b.

1.c. Conditional Permanent Resident (Proceed to Section B.)

Reason for Application (Select only one box)

Section A. (To be used only by a lawful permanent resident or a permanent resident in commuter status.)

Part 2. Application Type (continued)

Section B. (To be used only by a conditional permanent resident.)

Part 3. Processing Information

Biographic Information

6.Ethnicity (Select only one box)

Hispanic or Latino

Not Hispanic or Latino

7.Race (Select all applicable boxes)

White

Asian

Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

1.Location where you applied for an immigrant visa or adjustment of status:

2.Location where your immigrant visa was issued or USCIS office where you were granted adjustment of status:

Complete Item Numbers 3.a. and 3.a1. if you entered the United States with an immigrant visa. (If you were granted adjustment of status, proceed to Item Number 4.)

3.a. Destination in the United States at time of admission

9.Weight

10.Eye Color (Select only one box)

11.Hair Color (Select only one box)

Pounds

Brown

Hazel

Unknown/Other

Blond

Red

Unknown/Other

3.a.1. Port-of-Entry where admitted to the United States:

City or Town and State

4.Have you ever been in exclusion, deportation, or removal proceedings or ordered removed from the United States?

Yes No

5.Since you were granted permanent residence, have you ever filed Form I-407, Abandonment by Alien of Status as Lawful Permanent Resident, or otherwise been determined

NOTE: If you answered "Yes" to Item Numbers 4. or 5. above, provide a detailed explanation in the space provided in Part 8. Additional Information.

Part 4. Accommodations for Individuals with Disabilities and/or Impairments (Read the

information in the Form I-90 Instructions before completing this part.)

NOTE: If you need extra space to complete this section, use the space provided in Part 8. Additional Information.

1.Are you requesting an accommodation because of your

If you answered "Yes," select any applicable boxes:

Part 4. Accommodations for Individuals with Disabilities and/or Impairments (continued)

Applicant's Contact Information

3.Applicant's Daytime Telephone Number

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

5.Applicant's Email Address (if any)

Part 5. Applicant's Statement, Contact Information, Certification, and Signature

NOTE: Read the Penalties section of the Form I-90 Instructions before completing this part.

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.

prepared this application for me based only upon information I provided or authorized.

Applicant's 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 of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.

I further 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 laws.

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

1)I reviewed and provided or authorized all of the information in my application;

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

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

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

Applicant's Signature

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

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

NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.

Part 6. 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)

Interpreter's Mailing Address

3.a. Street Number

and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

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

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 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 7. 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.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)

Part 8. 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. Include 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.

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

5.d.