O m No. ! 15-0023: Expires 1213 1 J10 10
Part 3. Processing Information
A. CityTTownlV~Ilape Rill11
                   of'                                         ...
Part 3. Processing Information (Corliintrecl'J
C. List your present and p...
Part 3. Processing Informalion (Conrj~rzwd}
 5. Do you intend to engage in the United States in:
    a. Espionage?      ...
Part 3 Processing Information !C'unrinue~lJ

17. Have you EVER assisted or participated in selling or providing we...
Form I 485 (Scanned)
Upcoming SlideShare
Loading in...5

Form I 485 (Scanned)


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Form I 485 (Scanned)

  1. 1. O m No. ! 15-0023: Expires 1213 1 J10 10 6 Drpartmcnt of Homeland Security Form 1-485, Application Register U S Citi7snship and lrnmrgration Services Permanent Residence or Adjust Status ST.Kf HElit.: - 'I'yl~r Prirrt ( h s c h!;icIi i n k ) or !;or. I;SC15 I , s c Olll) Part 1 . Ilnli~rmotion ,bout You I<~'ti~~ncd Eir.r.r.1111 /== i I 1 . 1, I C;L>L'TIR I I ~ C N (fir31Narr~u) Middle Name I I I -Address - Street Number and Name C/O (in core nfl 1 I I Apt. # Kcsubmitted I Statc Zip Codc Rcloc Sent Date of Birth (mm/d~i'(~?yv) Country of Biflh I Country of Citizenshipmationnlity U.S. Social Security # (if my) A # 0j'an.v) I<cloc Rcc'd I I I - 1 EL- Date of Last Arrival (mm/dd(v:yv) 1-94 # 9 I 9 I I I Applicant Current USCIS Status Expires on (mm/dd(yyvv) Intcrv~ewcd I Part 2. Application Type (CIIPL~; T P ) CI~ I arn applyir~g an a r l j ~ ~ s t n ~ e npernlanent resident status hecsusc: for to t Sec Z O Q ~ ~ TNA ), a. An ~mrnig-ant pctition giving me an immediately available immigrant visa number sec. 2ns(b), INA Sec I?. Act uT9111157 that Eias hcen approved. [Attach a copy oftlie approval notice, or a rclativc, special Scr. 245, INA i~nrnigrant juvenile, or special immigrant military visa pctition filed with this Sec. ?4Q, INA application that will give you an immcdiatcly nvailable visa number,if approved.) Svc [ Acl LIT lI!?'h6 b. 17 My spouse or parent applied for adjustment of status or was granted lawful permanent residence in an irnrnigri3nt visa category tha~ allows derivative status for spouses and children. Country Chargcahlc c. E cntercd as a K-1 fiancC(c) oFa U.S. citizen whom I married within 40 days of entry, or 1am the K-2 child of such a t?m~ct(c). (Attach a copy of the fiancd(c) petition approval notice and the marriage certificate.) Eligibility Undcr Scc. 245 d. [3 1 was granted asylum or derivative asylum status as the spouse or chiId af a person hpprovcd Visa Pclition endcnt of Prlncrpal Alien - granted asylum and am eligible for ndjustmcnt. Sprcial Irnm~gant e. U 1 am a native or citizen of Cuba admitted or paroled into the United States after January 1 , 1959, and thereafter I-tave becn physically prcscnt in the United Stales for at least I year. Prcfrrcncc f. I am the husband, wife, or minor unmarried child of a Cuban described above in Action Bluck (el, and I a!m rcsiding with that person, and was admitted or parolcd into ttlc United I Statcs after January 1, 1 959, and thcrcaftcr have been pliysically present in the U~iitcdStalcs for a l least I ycar. g. I have continuousIy rcsided in the United States since before January 1, 1972. h. [7 Other basis of eligibility. Explain (for cxsmple, I WRY admitted as a refugcc, my status has not been ~erminatcd, and I have bcen physically prcscnt in the United States for 1 ycar affcr ndmission). ITadditional space is needed, see Page 2 of 111c I am already a, permanent resident and am applying to have the date I was granted 1 I r l be Ouniplctrd I I ~ permanent residence adjusted to the datr ! nriginally arrived in the United States as Allnrnc,~ R ~ p r t ~ s c ~ i t aI# fanyr , ur T ~~ a nonimmigrant o r parolee, o r as ul' May 2, 19434. whichever date is later, and: Pillill hor irl7orn] -5-28 i s artached lo rt'l7uck OIlr) the rcprrsen~ applrcnnl. i. I am a native or citizen of Cuba and rncct thc description in (e) above. VOLAG W j. I am thc husband, wife, or minor unmarried child of a Cuban and mecl thc descrinticln in Cfi abovc.
  2. 2. Part 3. Processing Information A. CityTTownlV~Ilape Rill11 of' Current Occupation I I I Your Mother's First N m c Your Father's First Name 1e Give your name exactly as it appears on your Form 7-94, Arrival-Departwe Record I I Place of Last Entry Into thc United States In what status did you last enter? (Visitor, stt~det71, c-~chnnge (CirvfSmte) visirur, urcwmcrrt, temporuql work~r. v i ! l ~ o ~it ~ ~ ~ p e c l ieft'.) v t on, I Wcre you inspcctcd by a U.S. Immigration Officer? Ycs No Nanimmigrant Visa Number Consulate Where Visa Was Issued I Date Visa I ssu~cd(mrn/dd@,v,vy) Gender Marital Status Male Femnle 17 Manied Single Divorced Widowed resident status in tlrc U.S,? Havc you ever applied for pcrma~ncnt Yes (Jf re.^" give n'al~ 1 1 d ~ 1 n r . e ~ C ] No ,filing andfiral disposirio>~.) R. List your prcscnt spouse and a11 of your childrcn (include adult sons and daughters). (If you have none, write "None." If additional space is necded, sce Page 2 of the instructions.) N Fa~nily amc (Lns! Nmnrl I Given Name (First N m e ) I Middle Initial 1 Date o f Birth ( m m / c f d ( ~ ) Country of Birth Relationship [ A 8 (!/'un-v?) Applying with you'? Yes NO Fatnily Name (Lwi Nmne) Givcn Name (FirsrName) PP Middle liritial Daze o f R i r t b (~rmr/rir//~?!~yj Yes U No U Famf 1y Name (Lcr.vl Natnc) Given Naine (First N m n ~ ) Initial Date oi' Rirlh (w~n/~lu(vi:~y~l M~ddlc Country ofBirth 1 Relationship I A # ([fanv) ) Applying with you? I YCS NO Family Name {l,os!Nume) Given Name (Firs1 Name) Middle rnitial Untc ol'Binh (t~7nr/'ddO;y,~-) Country of Birth Relationship A # (ferry) Applying with you? 7- F~rnily game (Lust ,Ynmr) Given Name (Firs! Numu) Middle Initial Datc or Birt 11 (rrirnJcid!~!~?!p) I Country of Birth Rclationship A # (ymtv) Applying with you? Yes No Form 1-485 (Rev. t 2/!,(13109) Page 2 N
  3. 3. Part 3. Processing Information (Corliintrecl'J it] C. List your present and past membersl~ip or afliliation with cvcry organization, association, fund, foundation, party. club, soctety, or sirniIar group in tlic United Statcs or in other places since your T 6th birthday. IncIude any military service in this part. If none, write "None." Include the namc of each organization, location, nature, and dates or mcmbcrship. ITaddilionial spacc is needed, attach a scpamte shect OF paper. Continuation pagcs must be submitted according to the guidelines provided on Page 2 ol'the instructions under "What Arc the General Filing Instructions"!" Date of Membership Date of Membership Name of Orgsniz~tion Location and Nature From 'Ta Answer the following questions. (If your answer is "Yes" to any question, explain on a separatc piccc of papcr. Continuation pages must bc submitted according to the guidcIincs provided on Page 2 01-the instructions under "What Are tl~c General Filing Instructions?" Information about documcntntion that inust be iilcludc with your application is also provide in this scction.) Answering "Yes" does not necessarily mean that yau are not entitIcd to adjust status or register for permanent rcsfdcncc. 1. Havc you EVER. in or outside thc United States: a. Knowingly committed any crime of n ~ o n turpitude or a drug-related offense for which you havc not hccn l Yes No arrested'? b Been arrested, citcd, charged, indicted, convicted, fined, or imprisoned for breaking er violating any law . Yes rr] No or ordinance, excluding tmffic ~ i ~ l i i t i ~ n ~ ? decree, other act of clemency. or similar action? c. Been thc beneficiary of a pardon. amnesty, ~~ehabditation Yes No d. Exercised diplomatic immunity to avoid prosecution for a criminal offcnse in the United States? ~ e s n on 2. Havc you received public assistance in the United Sratcs from any source, including thc U.S. Govemn~ent or Ycs No any State. county, city, or rnunicipaIity (other than emergency medical treamcnt), or are you likely to rcceivc public assistance in the future? 3. Havc you EVER: a. Within the past 10 ycars bccn a prostitute or procured anyone for prostitution, or intend to engage in such Ycs [7 No activities in the future? b. Engaged in my unlawfi~l cornrncrcializcd vice, including, but not limited to, iIlcgal gambling? NOD YCSC] c. Knowingly encouraged, induccd, assisted, abetted. or aided any alien to try to cntcr the United States Y c s n No ilIegallya? d. Illicitly traFficked in any controlled substancc. or knowingly assisted, abetted, or colludcd in the illicit Ycsn NO^ trafficking of any controlled substance'? 4. Have you EVER engaged in, conspired to engage in, or do you intend; to engage in, or havc you ever solicited Yes No 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 engagt. in sabotage, kidnapp~ng, political assassination, hijacking, ar any other form of terrorist activity? IRlllIlI!lIll1lI lll!l llIl11 IIIIlIIIIllllllllll IIlI lIl l l R I l lI 1 l 1 ) I ll Form 1-415 (Rev. 15/03/09) N P q c 3
  4. 4. - Part 3. Processing Informalion (Conrj~rzwd} 5. Do you intend to engage in the United States in: a. Espionage? Y C S ~ N~C] b. Any activity a purposc of which is opposition to, or the control or overthrow oi; the Government of the Yes No United Statcs, by force, violence, or other unlawful means? c. Any activity to violate or evadc any law prohibiting the cxpon from the United States of goods, yeso N o 0 tcc hnoIogy, or sensitive information? 6. Havc you EYER been a member of, or in any way affiliated with, the Communist Party or any other Ycsu N o 0 totalitarian party'? 7. Did you, during the period from March 23, 1933, to May 8, 1945, in association with eithcr the Nazi Ycsn N o 0 Govcrnmcnt of Gcrmany or m y organization or govcmmcnt associated or allied with thc Nmi Govcrnmcnt of G m a n y , ever order, incite, assist, or othenvise participate in the persecution of any person because of race, religion, national origin, or political opinion? 8. Have you EVER been departed from thc United States, or removed from the United States at govcmment Yes No 1 cxpcnsc, excluded within the past ycar, or are you now in exclusion, deportation, removal, or resc~ssioi~ proceedings? 9. Are you under a f i n d ordcr or civil penalty for violating section 274C of the Immigration and Nationality Yes No Act for use of fraudulent documents or l t ~ v eyou, by fraud or willhl misrepresentation of a material fact, ever sought to procum, or procured, a visa, other documcntnrion, entry into the Unitcd Statcs, or any immigration benefit? 10. Have you EVER left the United Stntes to avoid being drafted into the U.S.Armed Forces? yeso NO^ d l . Have you EVER been a J nonirnmigrant exchange visitor who was subject to thc Zycar foreign residence Ycs Q No requirement and havc not yet complicd with that requireme~ttor obtained a waivcr? 12. Arc you now withholding custody of a U.S. citizen child outside the United Statcs from a pmson granted Yes No custody of the child? 13. Do you plan to practicc polygamy in the United States? yeso NO^ 14. Have you EVER ordered, incited, called for, committed, assistcd, helped with, or otllenvise participated in any of thc following: a. Acts involving torture or genocide? NO ~ e s a a b. Killing any person? Yeso y o n c. intcntionnlly and sevcrely injuring any person? Yeso Nor] d. Engaging in any kind of sexual contact or rela~ions with any perso11 who was being forced or threatened? Yes No e. Limiting or denying any person*^ ability to cxcrcise rcIigious beliefs? ~ e s Q NOC] 15. FFave you EVER: a. Served in, been a member of, assistcd in, or participated in any military unit, paramilitary LIRII, poIice unti, 1 ' ~ s hu self-defense unit, vigilante unit. rcbel group, guerrilla group, militia, or insurgent organization? b. Servcd in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved Ycs No detaining persons? 16. Have you EVER been a mcmber of, assisted in, or participated in any group, unit, or organization of any Yes No kind in w h ~ c h or other persons uscd m y type of wcapon against any person or threatened to do so? you Form 1-485 (Rev 12/03/09) N Pagc 4
  5. 5. Part 3 Processing Information !C'unrinue~lJ . 17. Have you EVER assisted or participated in selling or providing weapolls to any person who to your Ycsm N o 0 knowledge used them against another person, or in tmnsponing weapons to any person who to your knowlcdgc used them against another person? 18. IIavc you EVER rcccived any type of military, paramilitary, or weapons training? Ycsn NOD Part 4. Accommodations for Individuals With Disabilities andlor impairments ( S r v I'uge I # oj'tlzc mstr~rclion,~ -- rllis before con~pletir~): secrion.j - Arc you rcquesting an accommodntion becausc of your disability(ies) andlor impairment(s)? if you answercd "Yes,"check any applicable box: a. I am deaf or hard of hearing and request the following accommodation(s) (if requesting a sign-languageinterpreter, indicate which languagc (c.g.. American Sign Language)): I I b, I am blind or sight-impaircd and request the following accommodation(s): c. 1 have another type o f disability andlor irnpairn~ent(describe the nature o f your disabilitv(ics) and/or irnpairmcnt(s) nnd accornmodation[s) you arc requesting): Part 5. Signature (Re~rd it!ji>tnrorio,7 pennlriu 011 Page 10 qf'rhr itnit-uctiotw befbre con~plc~tinl: seu!iurr. Yoz, ihe or? this mrrsr$Je lhis opplicafion while in the UniredSra~es.) Your Registration With U.S. Citizenship and Immigration Services "I understand and acknowledge that, under section 262 of the Immigration and Nationality Act (INA), as an alien who has been or will be in the United States for more than 30 days, I am required to register with U.S.Citizenship and Immigration Services (USCIS). I understand and acknowledge that, u~ldcr section 265 of thc INA, I am required to provide USCIS wit11 my current addrcss and written notice of m change of address within 10 days of the change. I undcmtand and acknowledge that USCIS wilI usc the most rcccnt y addrcss that I provide to USCIS, on any form containing these ackno~vledgements,For all purposes, includii~g service of a Norice the to Appear should it be necessary Tor USCIS to initiate rcmaval proccedings against me. I understand and acknowIcdgc that if I change my address without providing tvrittcn noticc to USCIS, I will be held responsible for any communications sent to me a t the most reccnt addrcss that I provided to USCIS. 1 further understand and acknowicdge tlrat, if removal proceedings are initiated against me and I fail to attcnd any hcarlring, including an initial hearing based on service o f the Noticc to Appear at the most recent addrcss that 1 provided to USCIS or as otl~envise provided by law, I may be ordercd removed in my absence, arrested, and rcrnovcd from Ilre United Stntcs." Selective Service Registratinn The following applies d you if you are a male at least I8 pears of age, but not yet 26 years- of age, wha is required to register o with the Selcctivc Service System: "I understand that my filing Form 1-485 with U.S. Citizenship and Immigration Scrvices (USCIS) authorizes USCIS to providc ccnain regislration information to the Sclcctivc Scrvicc System in accordance with the Military Selcctivc Service Act. Upon USCIS acceptance of my application, I authorize USCIS to transmit to the Selectrvc Service System my name, current address, Social Security Number, datc of birth, and the date I tiled the application for the purpose of recording my Selective Service registration as of the filing date. lf, howcves, USCJS does not accept my application, t firrther undcrsrand that, if so required, I am rcsponsiblc for registcriilg with the Selective Service by other means, provided I have not yet reached 26 ycars o f age." Form I-485(Rev. 12/I)3/09) Page 5 Y