I90 Form Online – Fill Out and Use This PDF

For

USCIS

Use

Only

Applicant Interviewed

Date:

Class of Admission

Receipt

Remarks

Action Block

Your Full Name

NOTE: Your card will be issued in this name.

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

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

Yes (Proceed to number 4.a. - number 4.c.)

No (Proceed to number 5.a. - number 5.f.)

5.e. State

5.g. Postal Code

5.h. Province 5.i. Country

5.f. Zip Code

N/A - I never received my previous card. (Proceed to number 5.a. - number 5.f.)

Your name exactly as reflected on your Permanent Resident Card

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

4.a. Family Name

(Last Name)

4.b. Given Name

(First Name)

4.c. Middle Name

U.S. Physical Address

8.Date of Birth (mm/dd/yyyy) ►

9.City/Town/Village of Birth

10.Country of Birth

11.Class of Admission

12.Date of Admission (mm/dd/yyyy) ►

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

►

NOTE: If your conditional status is expiring within the next 90 days, then do not file this application. (See Form I-90 instructions for further information.)

My status is (Select only one box):

1.a.

1.b.

1.c.

2.g2. I have reached my 14th birthday and am registering as required. My existing card will expire before my 16th birthday. (If you are filing this form before your 14th birthday, or more than 30 days after your 14th birthday, do not select 2.g.2. You must select 2.j.)

2.h1. I am a permanent resident who is taking up commuter status.

My port of entry (POE) into the United States will be:

2.h1.1. City and State

Reason for Application (select only one box)

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

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

3.a.

3.b.

3.c.

3.d.

3.e.

Mother's Name

1.Given Name (First Name)

Father's Name

2.Given Name (First Name)

Additional Information

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

4.Location where immigrant visa was issued or USCIS office where adjustment of status was granted:

Did you enter the United States with an immigrant visa? Complete number 5.a. and number 5.a1. (If you were granted adjustment of status, proceed to number 6.)

5.a. Destination in United States at time of admission

Port of entry where admitted to United States:

5.a1. City and State

6.Have you ever been ordered removed from the United

7.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 judged to

NOTE: If you answered "Yes" to number 6 or number 7 above, provide a detailed explanation on a separate sheet of paper. You must include your Name and A-Number on the top of each sheet.

1.Are you requesting an accommodation because of a

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

I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking.

1.a. Signature of Applicant

1.b. Date of Signature (mm/dd/yyyy) ►

2.Daytime Phone Number ( ) -

NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, your application may be denied.

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

Preparer's Full Name

Provide the following information concerning the preparer:

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

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

2.Preparer's Business or Organization Name

Preparer's Mailing Address

Preparer's Contact Information

5.Preparer's E-mail Address (if any)

Declaration

To be completed by all preparers, including attorneys and authorized representatives: I declare that I prepared this benefit request at the request of the applicant, that it is based on all the information of which I have knowledge, and that the information is true to the best of my knowledge.

6.a. Signature

of Preparer

6.b. Date of Signature (mm/dd/yyyy) ►

NOTE: If you require more space to provide any additional information, use a separate sheet of paper. You must include your Name and A-Number on the top of each sheet.