Please complete this questionnaire once for each member of your immediate family who will be applying for adjustment with you.

Date you are filling out this questionnaire:

Name (first/middle/last):
Other names used:
Maiden name:
Previous marriage(s):

Contact Information:
Phone (home):
Phone (work):
Fax:
E-mail:

Travel plans in next 6 months:
Where:
When:
Expected Length of Trip:

Date of birth (month/day/year):
Place of birth:
City:
Country:

Nationality:

Alien Registration No.:

Social Security No.:

Parent's Information:

Father:
Family name:
First name:
Date of birth:
Place of birth (city/country):
Residence (city/country):
If deceased, give date:

Mother:
Family (Maiden) name:
First name:
Date of birth:
Place of birth (city/country):
Residence (city/country):
If deceased, give date:

Former Husband/Wife, if any:
Family/Maiden name:
First name:
Date of birth:
Date of marriage:
Place of marriage:
Date of termination:
Place of termination:

Residences within last 5 years:
Street Address
City
State
Country
Dates (mo/yr)
From To

Last residence outside of U.S.:

Employment within last 5 years:
Company Name
Address
Position(s)
Dates (mo/yr)
From To

Last employment abroad:

Name in your native alphabet (if not Roman alphabet):

Arrival in the U.S.:
Date of Last Arrival in U.S.:
I-94 card number:
Name exactly as it appears on I-94 card:
Place of last entry into U.S.:
In what status did you enter the U.S.?:
Were you inspected:
Nonimmigrant visa number:
Consulate where visa was issued:
Date visa was issued (mo/day/year):

Current INS status:
Date current status expires (mo/day/year):
Have you ever applied for permanent resident status:

Marital Info (check one):
___ Married
___ Single
___ Divorced
___ Widowed

If married: Date: Place:

Family Information:
Name
Male or Female
Date of birth
Country of birth
A#
Apply with you?

Husband/Wife:
Children:

Present and past membership in or affiliation with every political organization, association, fund, foundation, party, club, society or similar group in the U.S. or in other places since your 16th birthday:

Name of Organization
Location
Dates
Nature of Organization:

Please answer the following questions. If your answer is Yes to any one of these questions, please explain. Answering Yes does not necessarily mean that you are not entitled to adjust your status or register for permanent residence. If you will be e-mailing this questionnaire back to us, please delete the answer that does not apply. If you will be printing this questionnaire and mailing the completed questionnaire back to us, please circle the correct answer.

Have you ever, in or outside the U.S.:

1. Knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?

Yes or No

2. Been arrested, cited, charged, indicted, fined or imprisoned for breaking or violating any law or ordinance, excluding traffic violations?

Yes or No

3. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?

Yes or No

4. Exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.?

Yes or No

5. Have you received public assistance in the U.S. from any source, including the U.S. government or any state, county, city or municipality (other than emergency medical treatment), or are you likely to receive public assistance in the future?

Yes or No

6. Have you ever:

a. Within the past ten years been a prostitute or procured anyone for prostitution, or intended to engage in such activities in the future?

Yes or No

b. Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?

Yes or No

c. Knowingly encouraged, induced, assisted, abetted or aided any alien to try to enter the U.S. illegally?

Yes or No

d. Illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of any controlled substance?

Yes or No

7. Have you ever engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited membership or funds for, or have you through any means ever assisted or provided any type of material support to, any person or organization that has ever engaged or conspired to engage, in sabotage, kidnapping, political assassination, hijacking or any other form of terrorist activity?

Yes or No

8. Do you intend to engage in the U.S. in:

a. Espionage?

Yes or No

b. Any activity a purpose of which is opposition to, or the control or overthrow of, the government of the United States, by force, violence or other unlawful means?

Yes or No

c. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology or sensitive information?

Yes or No

9. Have you ever been a member of, or in any way affiliated with, the communist party or any other totalitarian party?

Yes or No

10. Did you, during the period from March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist or otherwise participate in the persecution of any person because of race, religion, national origin or political opinion?

Yes or No

11. Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of any person because of race, religion, nationality, ethnic origin or political opinion

Yes or No

12. Have you ever been deported from the U.S., or removed from the U.S. at government expense, excluded within the past year, or are you now in exclusion or deportation proceedings?

Yes or No

13. Are you under a final order of civil penalty for violating section 274C of the Immigration and Nationality Act for use of fraudulent documents or have you, by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the U.S. or any immigration benefit?

Yes or No

14. Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?

Yes or No

15. Have you ever been a J nonimmigrant exchange visitor who was subject tot the two-year foreign residence requirement and not yet complied with that requirement or obtained a waiver?

Yes or No

16. Are you now withholding custody of a U.S. citizen child outside the U.S. from a person granted custody of the child?

Yes or No

17. Do you plan to practice polygamy in the U.S.?

Yes or No

Employment Authorization:
Have you ever applied for a work permit before?

Yes or No

If yes, when and where?
When:
What INS office:
If yes, what was the result?

Please attach legible copies of the following, as applicable:

_ birth certificate, marriage certificate, divorce decree (if applicable)
_ complete passport and I-94 card (front and back)
_ certified English translations of all foreign language documents
_ Forms I-20, IAP-66, Employment Authorization cards (if any)
(contact us for assistance in this regard, if necessary) _ Approval notice for prior applications
_ Two year residency requirement waiver approval notice
_ Any other documentation of your immigration history
(for prior J visa holders, if applicable)
_ INS photos (number varies based on what applications are being filed. Provide 3 for I-485, 2 for I-131, 3 for I-765
_ Driver’s license and social security card
_ Original INS doctor’s medical exam report in sealed, unopened envelope

(rev. 8/02)