City/Town/Village of Birth *
Country of Birth *
Country of Citizenship or Nationality *
USCIS Online Account Number (if any)
U.S. Social Security Number (if any)
Mailing Address: In Care of Name (if any) *
Alternate/Safe Mailing Address: In Care of Name (if any)
Passport Number Used at Last Arrival
Travel Document Used at Last Arrival
Country that Issued this Passport or Travel Document
Nonimmigrant Visa Number from this Passport (if any)
Place of Last Arrival Into the United States (City or Town, and State)
What were you admitted as: *
What were you admitted as: *
Explain other: *
Form I-94 Arrival-Departure Record Number (if any)
Status on Form I-94 (for example, class of admission, or paroled, if paroled)
What is your current immigration status (if it has changed since your arrival)?
Other eligibility: *
If you are the PRINCIPAL APPLICANT, provide the receipt number of underlying petition. (if any)
Principal Applicant's A-Number (if any)
Receipt number of Principal Applicant's underlying petition. (if any)
Enter City and Country of the U.S. Embassy or U.S. Consulate *
Decision (for example, approved, refused, denied, withdrawn) *
How many times have you been married? (including annulled marriages and marriages to the same person)
A-Number (if any)
Current Spouse's Place of Birth - City or Town, State or Province, and Country
Place of Marriage to Current Spouse - City or Town, State or Province, and Country
Place of Marriage to Prior Spouse - City or Town, State or Province, and Country
Place of Marriage to Prior Spouse - City or Town, State or Province, and Country
City/Town/Village of Birth *
Country of Birth *
Current City/Town/Village of Residence (if living)
Current Country of Residence (if living)
City/Town/Village of Birth *
Country of Birth *
Current Country of Residence (if living)
Current City/Town/Village of Residence (if living)
Name of Employer/Company 1 *
Your Occupation:
Name of Employer/Company 2
Your Occupation:
Name of Employer/Company 3
Your Occupation:
Height (in feet and inches) *
Weight (in pounds) *
A-Number (if any)
Country of Birth
A-Number (if any)
Country of Birth
A-Number (if any)
Country of Birth
A-Number (if any)
Country of Birth
A-Number (if any)
Country of Birth
Name of Organization 1 *
City or Town of Organization 1 *
State or Province of Organization 1 *
Country for Organization 1 *
Nature of Group for Organization 1 *
Name of Organization 2
City or Town of Organization 2
State or Province of Organization 2
Country for Organization 2
Nature of Group for Organization 2
Name of Organization 3
City or Town of Organization 3
State or Province of Organization 3
Country for Organization 3
Nature of Group for Organization 3
Explain your answer: *
Explain your answer: *
Explain your answer: *
Explain your answer: *
Explain your answer: *
Explain your answer: *
Explain your answer: *
Explain your answer: *
Explain your answer: *
Explain your answer: *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes why you were arrested, cited, detained, or charged; where you were arrested, cited, detained, or charged; when the event occurred (date); the outcome or disposition (for example no charges filed, charges dismissed, jail, probation, community service) *
Provide an explanation that includes dates, details, parental information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Provide an explanation that includes dates, details, information, and anything else pertinent to the occurrences. *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain what you did, including dates and location of the circumstances, or what you intend to do: *
Explain the relationship, what occurred, including the dates and locations of the circumstances: *
Explain the relationship, what occurred, including the dates and locations of the circumstances: *
Explain the relationship, what occurred, including the dates and locations of the circumstances: *
Explain the relationship, what occurred, including the dates and locations of the circumstances: *
Explain the relationship, what occurred, including the dates and locations of the circumstances: *
Explain the relationship, what occurred, including the dates and locations of the circumstances: *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
Explain what occurred, including the dates and location of the circumstances. *
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) *
Accommodation Request: *
What is the language in which you are fluent? *
Preparer Business or Organization Name (if any)
Preparer's Daytime Phone Number *
Preparer's Mobile Phone Number
Preparer's Email Address
Interpreter Business or Organization Name (if any)
Interpreter's Daytime Phone Number *
Interpreter's Mobile Phone Number
Interpreter's Email Address
I, the interpreter, certify under penalty of perjury, that I am fluent in English and: (Must be same language that you interpreted for the Petitioner)
Applicant's Daytime Phone Number *
Applicant's Mobile Phone Number
Applicant's Email