Adjustment of Status Questionnaire

SECTION 01 · ADJUSTMENT OF STATUS

Applicant identity and contact

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Applicant — First/given name *

Applicant — Family/last name *

Applicant — Middle name

Applicant contact email address *

Date of birth

Ever used a different date of birth?

Other dates of birth

Entry 1

Other birth date

Have an A-number?

Current A-number (if any)

Ever assigned another A-number?

Other A-numbers

Entry 1

A-number

Sex (as requested by USCIS)

City or town of birth

Country of birth

Country of citizenship or nationality

USCIS Online Account Number

Phone number

SECTION 02 · ADJUSTMENT OF STATUS

Most recent entry and immigration documents

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Passport or travel document number used at last arrival

Passport or travel document expiration date

Country issuing passport or travel document

Nonimmigrant visa number used at most recent arrival

Date most recent nonimmigrant visa issued

Last arrival — City or town

Last arrival — State

Date of last arrival

Most recent entry

Status/class of admission or parole at last entry

Other entry circumstances

Most recent I-94 number

Name appearing on most recent I-94

I-94 authorized stay expiration (or D/S)

Status or class on I-94

Was your last arrival your first time physically present in the United States?

Current immigration status, if changed since admission

Current status expiration date or D/S

Ever issued an alien crewman visa?

Last entered as seaman/crew member or aboard vessel/aircraft?

SECTION 03 · ADJUSTMENT OF STATUS

US and foreign address history

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Current US physical address — Street number and name

Current US physical address — Unit type (Apartment, Suite, Floor)

Current US physical address — Unit number

Current US physical address — City or town

Current US physical address — State

Current US physical address — ZIP code

Current US physical address — Province

Current US physical address — Postal code

Current US physical address — Country

Date began residing at current US address

Is your current US physical address also your mailing address?

Mailing or safe alternate address — Street number and name

Mailing or safe alternate address — Unit type (Apartment, Suite, Floor)

Mailing or safe alternate address — Unit number

Mailing or safe alternate address — City or town

Mailing or safe alternate address — State

Mailing or safe alternate address — ZIP code

Mailing or safe alternate address — Province

Mailing or safe alternate address — Postal code

Mailing or safe alternate address — Country

Have you lived at your current address at least five years?

Previous addresses in last five years

Entry 1

Street and number

Unit/apartment/suite

City

State

ZIP code

Province

Postal code

Country

Date from (YYYY-MM-DD)

Date to (YYYY-MM-DD; blank if current)

Most recent physical address outside the US where you lived over one year — Street number and name

Most recent physical address outside the US where you lived over one year — Unit type (Apartment, Suite, Floor)

Most recent physical address outside the US where you lived over one year — Unit number

Most recent physical address outside the US where you lived over one year — City or town

Most recent physical address outside the US where you lived over one year — State

Most recent physical address outside the US where you lived over one year — ZIP code

Most recent physical address outside the US where you lived over one year — Province

Most recent physical address outside the US where you lived over one year — Postal code

Most recent physical address outside the US where you lived over one year — Country

Most recent physical address outside the US where you lived over one year — Date from

Most recent physical address outside the US where you lived over one year — Date to (leave blank if present)

SECTION 04 · ADJUSTMENT OF STATUS

Social Security information

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Has the Social Security Administration issued you a Social Security card?

Applicant US Social Security number (if issued)

Do you want SSA to issue you a Social Security card?

Do you authorize required information disclosure to SSA for issuance?

SECTION 05 · ADJUSTMENT OF STATUS

Adjustment classification and petition

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Are you filing Form I-485 with EOIR while in removal/exclusion/deportation/rescission proceedings?

Underlying petition receipt number

Priority date of underlying petition

Filing as

Principal applicant (if filing as derivative) — First/given name

Principal applicant (if filing as derivative) — Family/last name

Principal applicant (if filing as derivative) — Middle name

Principal applicant A-number

Principal applicant date of birth

I-485 filing / immigrant classification (select one)

Other classification or special statutory basis

For an I-140 case: did a relative petition or own 5% or more of sponsoring employer?

Relationship of I-140 petitioner/business owner

Relative citizenship or immigration status

Date granted asylum if applicable

Initial admission date as refugee if applicable

Diversity Visa rank number if applicable

Applying under INA 245(i)?

Age 21 or older and applying as a child under CSPA?

SECTION 06 · ADJUSTMENT OF STATUS

Affidavit of Support need or exemption

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Is an I-864 required or are you requesting an exemption?

SECTION 07 · ADJUSTMENT OF STATUS

Prior permanent residency and employment / education

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Ever applied for an immigrant visa at a US embassy/consulate?

Consulate city

Consulate country

Visa case decision

Decision date

Previously applied for permanent residence while in the United States?

Ever had lawful permanent resident status rescinded under INA 246?

Employment, education, unemployment, retirement: last five years

Entry 1

Employer, school or activity

Job title or activity

Street address

City

State

Country

Date from

Date to

Source of financial support if unemployed/retired

Most recent employer or school outside US if not listed above

Entry 1

Employer, school or activity

Job title or activity

Street address

City

State

Country

Date from

Date to

Source of financial support if unemployed/retired

SECTION 08 · ADJUSTMENT OF STATUS

Applicant parents

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Parent 1 current legal name — First/given name

Parent 1 current legal name — Family/last name

Parent 1 current legal name — Middle name

Parent 1 name at birth — First/given name

Parent 1 name at birth — Family/last name

Parent 1 name at birth — Middle name

Parent 1 date of birth

Parent 1 country of birth

Parent 2 current legal name — First/given name

Parent 2 current legal name — Family/last name

Parent 2 current legal name — Middle name

Parent 2 name at birth — First/given name

Parent 2 name at birth — Family/last name

Parent 2 name at birth — Middle name

Parent 2 date of birth

Parent 2 country of birth

SECTION 09 · ADJUSTMENT OF STATUS

Applicant current and prior marriages

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Current marital status

Number of marriages (including current, past, abroad and annulled)

Is your spouse currently serving in US armed forces/Coast Guard?

Current spouse — First/given name

Current spouse — Family/last name

Current spouse — Middle name

Current spouse A-number

Current spouse date of birth

Current spouse country of birth

Current spouse physical address — Street number and name

Current spouse physical address — Unit type (Apartment, Suite, Floor)

Current spouse physical address — Unit number

Current spouse physical address — City or town

Current spouse physical address — State

Current spouse physical address — ZIP code

Current spouse physical address — Province

Current spouse physical address — Postal code

Current spouse physical address — Country

City where married

State or province where married

Country where married

Date of marriage

Is spouse applying for adjustment with you?

Previous marriages and how they ended

Entry 1

First name

Last name

Middle name

Prior spouse date of birth

Prior spouse country of birth

Prior spouse country of citizenship

Date married

Place married

Date marriage ended

Place where marriage legally ended

Reason marriage ended (divorce, annulment, death, other)

SECTION 10 · ADJUSTMENT OF STATUS

All living children (including adult, step and adopted children)

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Total number of all living children worldwide

Children and their adjustment filings

Entry 1

First name

Last name

Middle name

Child A-number

Date of birth

Country of birth

Biological, stepchild, adopted, etc.

Is child also filing Form I-485 now?

SECTION 11 · ADJUSTMENT OF STATUS

Applicant biographic information

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Ethnicity

Race (select a primary category; list others in notes)

Height — feet

Height — inches

Weight in pounds

Eye color

Hair color

SECTION 12 · ADJUSTMENT OF STATUS

Eligibility screening: organizations and immigration history

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

I-485 Part 9 Question 1: Ever been involved with any organization, party, association, group, club or society anywhere?

Organizations, roles, purposes and involvement dates

Entry 1

Organization name

City

State or province

Country

Organization purposes and activities

Your role or involvement

Membership date from

Membership date to

I-485 Part 9 Question 10: Have you EVER been denied admission to the United States?

I-485 Part 9 Question 11: Have you EVER been denied a visa to the United States?

I-485 Part 9 Question 12: Have you EVER worked in the United States without authorization?

I-485 Part 9 Question 13: Have you EVER violated the terms or conditions of your nonimmigrant status?

I-485 Part 9 Question 14: Are you presently or have you EVER been in removal, exclusion, rescission, or deportation proceedings, including expedited removal proceedings?

I-485 Part 9 Question 15: Have you EVER been issued a final order of exclusion, deportation, or removal?

I-485 Part 9 Question 16: Have you EVER had a prior final order of exclusion, deportation, or removal reinstated?

I-485 Part 9 Question 17: Have you EVER been granted voluntary departure by an immigration officer or an immigration judge but failed to depart within the allotted time?

I-485 Part 9 Question 18: Have you EVER applied for any kind of relief or protection from removal, exclusion, or deportation?

I-485 Part 9 Question 19: Have you EVER been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement?

I-485 Part 9 Question 20: If you answered "Yes" to Item Number 19., have you complied with the foreign residence requirement?

I-485 Part 9 Question 21: If you answered "Yes" to Item Number 19. and "No" to Item Number 20., have you been granted a waiver or has Department of State issued a favorable waiver recommendation letter for you?

Explanations about immigration history, including dates, prior refusals, J-1 issues, violations, or immigration proceedings

SECTION 13 · ADJUSTMENT OF STATUS

Eligibility screening: arrests, criminal and controlled substance matters

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

I-485 Part 9 Question 22: Have you EVER been arrested, cited, charged, or permitted to participate in a diversion program (including pre-trial diversion, deferred prosecution, deferred adjudication, or any withheld adjudication), or detained for any reason by any law enforcement official in any country including but not limited to any U.S. immigration official or any official of the U.S. armed forces or U.S. Coast Guard or by a similar official of a country other than the United States?

I-485 Part 9 Question 23: Have you EVER committed a crime of any kind (even if you were not arrested, cited, charged with, or tried for that crime, or convicted)?

I-485 Part 9 Question 24: Have you EVER pled guilty to or been convicted of a crime or offense (even if the violation was subsequently expunged or sealed by a court, or if you were granted a pardon, amnesty, a rehabilitation decree, or other act of clemency)?

I-485 Part 9 Question 25: Have you EVER been ordered punished by a judge or had conditions imposed on you that restrained your liberty (such as a prison sentence, suspended sentence, house arrest, parole, alternative sentencing, drug or alcohol treatment, rehabilitative programs or classes, probation, or community service)?

I-485 Part 9 Question 26: Have you EVER violated (or attempted or conspired to violate) any controlled substance law or regulation of a state, the United States, or a foreign country?

I-485 Part 9 Question 27: Have you EVER trafficked in or benefited from, or knowingly aided, abetted, assisted, conspired or colluded in the illegal trafficking of any controlled substances, such as chemicals, illegal drugs, or narcotics?

I-485 Part 9 Question 28: Are you the spouse, son, or daughter of an alien who illicitly trafficked or aided (or otherwise abetted, assisted, conspired, or colluded) in the illicit trafficking of a controlled substance, such as chemicals, illegal drugs, or narcotics and you obtained, within the last 5 years, any financial or other benefit from this activity of your spouse or parent?

I-485 Part 9 Question 29: If your answer to Item Number 28. is "Yes," did you know or should you have reasonably known that the financial or other benefit you obtained resulted from this activity of your spouse or parent?

I-485 Part 9 Question 30: Have you EVER engaged in prostitution or are you coming to the United States to engage in prostitution?

I-485 Part 9 Question 31: Have you EVER directly or indirectly procured or attempted to procure, or imported prostitutes or persons for the purpose of prostitution?

I-485 Part 9 Question 32: Have you EVER received any proceeds or money from prostitution?

I-485 Part 9 Question 33: Do you intend to engage in illegal gambling or any other form of commercialized vice, such as prostitution, bootlegging, or the sale of child pornography, while in the United States?

I-485 Part 9 Question 34: Have you EVER exercised immunity (diplomatic or otherwise) to avoid being prosecuted for a criminal offense in the United States?

I-485 Part 9 Question 35.a: Have you EVER served as a foreign government official?

I-485 Part 9 Question 35.b: If your answer to Item Number 35.a. is "Yes," have you EVER been responsible for, enforced, or directly carried out violations of religious freedoms?

I-485 Part 9 Question 36: Have you EVER induced by force, fraud, or coercion (or otherwise been involved in) the trafficking of another person for commercial sex acts (sex trafficking)?

I-485 Part 9 Question 37: Have you EVER trafficked a person into involuntary servitude, peonage, debt bondage, or slavery? Trafficking includes recruiting, harboring, transporting, providing, or obtaining a person for labor or services through the use of force, fraud, or coercion.

I-485 Part 9 Question 38: Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with others in trafficking in persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or slavery?

I-485 Part 9 Question 39: Are you the spouse, son, or daughter of an alien who engaged in the trafficking in persons and have received or obtained, within the last 5 years, any financial or other benefits from this activity of your spouse or your parent?

I-485 Part 9 Question 40: If your answer is "Yes" to Item Number 39., did you know or reasonably should have known that this benefit resulted from this activity of your spouse or parent?

I-485 Part 9 Question 41: Have you EVER engaged in money laundering or have you EVER knowingly aided, assisted, abetted, conspired, or colluded with others in money laundering or do you seek to enter the United States to engage in such activity?

For any Yes or uncertain answer: incident, date, location, arrest/citation/charge, disposition, sentence, probation and supporting records

SECTION 14 · ADJUSTMENT OF STATUS

Eligibility screening: security, military service and related conduct

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

I-485 Part 9 Question 42.a: Engage in any activity that violates or evades any law relating to espionage (including spying) or sabotage in the United States?

I-485 Part 9 Question 42.b: Engage in any activity in the United States that violates or evades any law prohibiting the export from the United States of goods, technology, or sensitive information?

I-485 Part 9 Question 42.c: Engage in any activity whose purpose includes opposing, controlling, or overthrowing the U.S. Government by force, violence, or other unlawful means while in the United States?

I-485 Part 9 Question 42.d: Engage in any other unlawful activity?

I-485 Part 9 Question 43.a: Received any weapons training, paramilitary training, or other military-type training?

I-485 Part 9 Question 43.b: Committed kidnapping, assassination, or hijacking or sabotage of a conveyance (including an aircraft, vessel, vehicle, or train)?

I-485 Part 9 Question 43.c: Used a weapon or explosive or any dangerous device with the intent to endanger the safety of another person or people or cause damage to property?

I-485 Part 9 Question 43.d: Threatened, attempted, conspired, prepared, or planned to do any of the things described in Item Numbers

I-485 Part 9 Question 43.e: Incited, under circumstances indicating an intention to cause death or serious bodily harm/injury, any of the activities described in Item Numbers 43.b. - 43.c.?

I-485 Part 9 Question 43.f: Participated in, or been a member of, a group or organization that did any of the activities described in Item Numbers 43.b. - 43.e.?

I-485 Part 9 Question 43.g: Recruited members or asked for money or things of value for a group or organization that did any of the activities described in Item Numbers 43.b. - 43.e.?

I-485 Part 9 Question 43.h: Provided money, a thing of value, services or labor, or any other assistance or support for any of the activities described in Item Numbers 43.b. - 43.e.?

I-485 Part 9 Question 43.i: Provided money, a thing of value, services or labor, or any other assistance or support for an individual, group, or organization who did any of the activities described in Item Numbers 43.b. - 43.e.?

I-485 Part 9 Question 44: Do you intend to engage in any of the activities listed in any part of Item Numbers 43.b. - 43.e.?

I-485 Part 9 Question 45: Do you intend to engage in any activity that could endanger the welfare, safety, or security of the United States?

I-485 Part 9 Question 46: Are you the spouse or child of an individual who EVER engaged in any of the activities listed in Item Numbers 43.b. - 43.i.?

I-485 Part 9 Question 47: Have you EVER sold, provided, or transported weapons, or assisted any person in selling, providing, or transporting weapons, which you knew or believed would be used against another person?

I-485 Part 9 Question 48: Have you EVER worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other place where people were detained, or have you EVER directed or participated in any other activity that involved detaining people?

I-485 Part 9 Question 49: Have you EVER been a member of, assisted, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so?

I-485 Part 9 Question 50: Have you EVER served in, been a member of, assisted (helped), or participated in any military or police unit?

I-485 Part 9 Question 51: Have you EVER served in, been a member of, assisted (helped), or participated in any armed group (a group that carries weapons), for example: paramilitary unit (a group of people who act like a military group, but are not part of the official military), self-defense unit, vigilante unit, rebel group, or guerrilla group?

I-485 Part 9 Question 52: Have you EVER been a member of, or in any way affiliated with, the Communist Party or any totalitarian party (in the United States or abroad)?

I-485 Part 9 Question 53.a: Torture?

I-485 Part 9 Question 53.b: Genocide?

I-485 Part 9 Question 53.c: Killing, or trying to kill, any person?

I-485 Part 9 Question 53.d: Intentionally and severely injuring or trying to injure any person?

I-485 Part 9 Question 54: Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to take part in hostilities or to serve in or help an armed force or group, or attempted or worked with others to do so?

I-485 Part 9 Question 55: Have you EVER used any person under 15 years of age to take part in hostilities, for instance, participating in combat or providing services related to combat (such as sabotage or serving as a courier) or providing support services (such as transporting supplies), or attempted or worked with others to do so?

Explain relevant affiliations, government, security, police, military or armed group activities, places, dates and roles

SECTION 15 · ADJUSTMENT OF STATUS

Public charge screening and household background

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

I-485 Part 9 Question 56: public charge exemption category

I-485 Part 9 Question 57: Family status / household size

Question 58: Annual household income

Question 59: Household asset value

Question 60: Household liability value

Question 61: Highest completed education

Highest grade if less than high school

Question 62: Skills, certifications, licenses and educational certificates

Certifications and licenses

Entry 1

Certificate or license

Issuing organization

Question 63: Ever received means-tested public benefits?

Question 64: Benefits received

Entry 1

Benefit

Start date

End date

Dollar amount

Reason received

SECTION 16 · ADJUSTMENT OF STATUS

Eligibility screening: immigration violations and other grounds

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

I-485 Part 9 Question 65: Have you EVER failed or refused to attend or to remain in attendance at any removal proceeding filed against you on or after April 1, 1997?

I-485 Part 9 Question 66: Have you EVER submitted altered, fraudulent, or counterfeit documentation to any U.S. Government official to obtain or attempt to obtain any immigration benefit, including a visa or entry into the United States?

I-485 Part 9 Question 67: Have you EVER lied about, concealed, or misrepresented any information on an application or petition to obtain a visa, other documentation required for entry into the United States, admission to the United States, or any other kind of immigration benefit?

I-485 Part 9 Question 68: Have you EVER falsely claimed to be a U.S. citizen (in writing or any other way)?

I-485 Part 9 Question 69: Have you EVER been a stowaway on a vessel or aircraft arriving in the United States?

I-485 Part 9 Question 70: Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any alien to enter or to try to enter the United States illegally (alien smuggling)?

I-485 Part 9 Question 71: Are you under a final order of civil penalty for violating INA section 274C for use of fraudulent documents?

I-485 Part 9 Question 72: Have you EVER been excluded, deported, or removed from the United States or have you ever departed the United States on your own after having been ordered excluded, deported, or removed from the United States?

I-485 Part 9 Question 73: Have you EVER entered the United States without being inspected and admitted or paroled?

I-485 Part 9 Question 74: Since April 1, 1997, have you been unlawfully present in the United States? You were unlawfully present in the United States if you were present in the United States after the expiration of the period of stay authorized by the Department of Homeland Security (DHS) Secretary or were present in the United States without being admitted or paroled.

I-485 Part 9 Question 75: If you answered “Yes” to Item Number 74., was a severe form of trafficking in persons at least one central reason for your unlawful presence in the United States?

I-485 Part 9 Question 76.a: Having been unlawfully present in the United States for more than one year in the aggregate on or after April 1, 1997? You were unlawfully present in the United States for more than one year in the aggregate if you count all of the days during all of your stays that you were present in the United States after the expiration of the period of stay authorized by the DHS Secretary or were present in the United States without being admitted or paroled.

I-485 Part 9 Question 76.b: Having been deported, excluded, or removed from the United States?

I-485 Part 9 Question 77: Do you plan to practice polygamy in the United States?

I-485 Part 9 Question 78: Are you accompanying an alien who is inadmissible and who has been certified by a medical officer as helpless from sickness, mental or physical disability, or infancy, and who requires your protection or guardianship, as described in INA section 232(c)?

I-485 Part 9 Question 79: Have you EVER assisted in detaining, retaining, or withholding custody of a U.S. citizen child outside the United States from a person who has been granted custody of the child?

I-485 Part 9 Question 80: Have you EVER voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or regulation in the United States?

I-485 Part 9 Question 81: Have you EVER renounced U.S. citizenship to avoid being taxed by the United States?

I-485 Part 9 Question 82.a: Applied for exemption or discharge from training or service in the U.S. armed forces or in the U.S. National Security Training Corps on the ground that you are an alien?

I-485 Part 9 Question 82.b: Been relieved or discharged from such training or service on the ground that you are an alien?

I-485 Part 9 Question 82.c: Been convicted of desertion from the U.S. armed forces?

I-485 Part 9 Question 83: Have you EVER left or remained outside the United States to avoid or evade training or service in the U.S. armed forces in time of war or a period declared by the President to be a national emergency?

I-485 Part 9 Question 84: Nationality/status before leaving to avoid military service, if applicable

Explanations for any Yes or uncertain inadmissibility answer (facts, locations, dates, prior proceedings and relief)

SECTION 17 · I-864 SPONSOR

Affidavit of Support: sponsor basis and legal status

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

I-864 Part 1: Sponsor type

If employment petitioner/owner: relationship to intending immigrant

If 5% owner: name of related petitioning business

If substitute sponsor: relationship to immigrant

Sponsor full legal name — First/given name

Sponsor full legal name — Family/last name

Sponsor full legal name — Middle name

Sponsor email address

Sponsor daytime telephone

Sponsor mobile telephone

Sponsor mailing address — Street number and name

Sponsor mailing address — Unit type (Apartment, Suite, Floor)

Sponsor mailing address — Unit number

Sponsor mailing address — City or town

Sponsor mailing address — State

Sponsor mailing address — ZIP code

Sponsor mailing address — Province

Sponsor mailing address — Postal code

Sponsor mailing address — Country

Is sponsor mailing address the same as physical address?

Sponsor physical address — Street number and name

Sponsor physical address — Unit type (Apartment, Suite, Floor)

Sponsor physical address — Unit number

Sponsor physical address — City or town

Sponsor physical address — State

Sponsor physical address — ZIP code

Sponsor physical address — Province

Sponsor physical address — Postal code

Sponsor physical address — Country

Sponsor country of domicile

Sponsor date of birth

Sponsor country of birth

Sponsor SSN (optional for client intake)

Sponsor citizenship/immigration status

Sponsor A-number

Sponsor USCIS account number

Petitioning sponsor currently on active duty in US armed forces or Coast Guard?

SECTION 18 · I-864 SPONSOR

Affidavit of Support: principal and additional immigrants

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Principal sponsored immigrant — First/given name

Principal sponsored immigrant — Family/last name

Principal sponsored immigrant — Middle name

Principal immigrant mailing address — Street number and name

Principal immigrant mailing address — Unit type (Apartment, Suite, Floor)

Principal immigrant mailing address — Unit number

Principal immigrant mailing address — City or town

Principal immigrant mailing address — State

Principal immigrant mailing address — ZIP code

Principal immigrant mailing address — Province

Principal immigrant mailing address — Postal code

Principal immigrant mailing address — Country

Principal immigrant country of nationality

Principal immigrant date of birth

Principal immigrant A-number

Principal immigrant USCIS online account number

Principal immigrant daytime phone

Sponsoring the principal immigrant?

Additional immigrants being sponsored

Additional immigrants sponsored on I-864

Entry 1

First name

Last name

Middle name

Relationship to principal immigrant

Date of birth

A-number

USCIS Online Account Number

SECTION 19 · I-864 SPONSOR

Affidavit of Support: household size and employment

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Number immigrants sponsored on affidavit

Sponsor (usually 1)

Spouse not counted above

Dependent children not counted above

Other dependents not counted above

Previously sponsored LPRs still supported

Other household family members combining income

Total household size

Sponsor employment status

Sponsor occupation/job title

Sponsor employer 1

Sponsor employer 2

Retired since

Unemployed since

Sponsor current annual individual income

Household members combining income

Entry 1

First name

Last name

Middle name

Relationship

Current annual income

Does member submit Form I-864A?

Current annual household income

Relevant household income providers have completed I-864A?

SECTION 20 · I-864 SPONSOR

Affidavit of Support: Federal income tax returns

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Filed federal tax returns for each of the past three years?

Not required to file because income below IRS threshold?

Tax year 1 (most recent)

Tax year 1 total income

Tax year 2 (2 year(s) ago)

Tax year 2 total income

Tax year 3 (3 year(s) ago)

Tax year 3 total income

SECTION 21 · I-864 SPONSOR

Affidavit of Support: assets used when applicable

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Cash, savings and checking accounts

Net cash value of real estate

Net value of stocks/bonds/other assets

Total sponsor assets

Household member assets from I-864A

Principal immigrant savings/checking

Principal immigrant net real estate

Principal immigrant securities/other

Total principal immigrant assets

Total assets proposed for I-864

Details of assets, owners, debts, liquidity and evidence if relevant

SECTION 22 · ADJUSTMENT OF STATUS

Additional information and supporting documents

Only the applicant’s first name, last name and email address are mandatory. Provide other information if known and applicable.

Additional facts, dates or explanations relevant to I-485 inadmissibility, eligibility, or I-864

Identity, admission, petition, medical, employment, financial, tax and other documents available for the case

Applicant identity and contact

Most recent entry and immigration documents

US and foreign address history

Social Security information

Adjustment classification and petition

Affidavit of Support need or exemption

Prior permanent residency and employment / education

Applicant parents

Applicant current and prior marriages

All living children (including adult, step and adopted children)

Applicant biographic information

Eligibility screening: organizations and immigration history

Eligibility screening: arrests, criminal and controlled substance matters

Eligibility screening: security, military service and related conduct

Public charge screening and household background

Eligibility screening: immigration violations and other grounds

Affidavit of Support: sponsor basis and legal status

Affidavit of Support: principal and additional immigrants

Affidavit of Support: household size and employment

Affidavit of Support: Federal income tax returns

Affidavit of Support: assets used when applicable

Additional information and supporting documents

Secure verification