Adjustment of Status Questionnaire

INFORMATION ABOUT YOU

Name

First

Middle

Last

Other Names Used 1

First

Middle

Last

Other Names Used 2

First

Last

Date of Birth

Email

Phone

Sex

Place of Birth (City / State / Country)

Country of Citizenship or Nationality

Alien Number (USCIS Number or A#)

Social Security Number (SSN)

Ethnicity

Race (Select All That Apply)

Height (Feet - Inches)

Weight in Pounds

Eye Color

Hair Color

YOUR FINANCIAL INFORMATION

What is the size of your household?

Indicate your annual household income.

Identify the total value of your household assets

Identify the total value of your household liabilities (including both secured and unsecured liabilities)

What is the highest degree or level of school you have completed?

List your certifications, licenses, skills obtained through work experience, and educational certificates.

Have you ever received Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), or State, Tribal, territorial, or local, cash benefit programs for income maintenance (often called "General Assistance" in the State context, but which also exist under other names?

Have you ever received long-term institutionalization government expense?

ADDRESS HISTORY FOR THE PAST 5 YEARS

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Date From

Date To

Prior Address 1

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date From

Date To

Prior Address 2

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date From

Date To

Prior Address 3

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date From

Date To

IMMIGRATION HISTORY

Passport Number Used At Most Recent Entery

Name of Country that Issued Your Passport

Date Passport Was Issued

Date Passport Expires

Location of US Embassy (City and Country) That Issued Your Visa Used to Enter the US

Nonimmigrant Visa Number

Place of Last Arrival to US (City, State)

Date of Last Arrival

I94 Number

I94 Expiration Date

Visa Status on I94

Current Visa Status

Date Current Visa Status Expires

Have You Ever Applied for an Immigrant Visa?

List Location of Embassy (City, Country)

Decision

Date of Decision

EMPLOYMENT HISTORY FOR THE PAST 5 YEARS

Employer 1 (Current or Most Recent)

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title

Employment Start Date

Employment End Date

Employer 2

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title

Employment Start Date

Employment End Date

Employer 3

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title

Employment Start Date

Employment End Date

Most Recent Employer Outside of The US If Not Listed Above

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Job Title

Employment Start Date

Employment End Date

INFORMATION ABOUT YOUR PARENTS

Father's Name

First

Middle

Last

Father's Name At Birth, If Different

First

Middle

Last

Date of Birth

Place of Birth (City & Country)

Place of Current Residence (City & Country)

Mother's Name

First

Middle

Last

Mother's Name At Birth, If Different

First

Middle

Last

Date of Birth

Place of Birth (City & Country)

Place of Current Residence (City & Country)

MARITAL HISTORY

What is Your Current Marital Status?

Current Spouse's Name

First

Middle

Last

Alien Number (USCIS Number or A#)

Date of Birth

Place of Birth (City / State / Country)

Date of Marriage

Place of Marriage (City / State / Country)

Prior Spouse's Name 1

First

Middle

Last

Date of Birth

Date of Marriage

Place of Marriage (City / State / Country)

Date Marriage Ended

Prior Spouse's Name 2

First

Middle

Last

Date of Birth

Date of Marriage

Place of Marriage (City / State / Country)

Date Marriage Ended

INFORMATION ABOUT YOUR CHILDREN

Child 1 Name

First

Middle

Last

Alien Number (USCIS Number or A#)

Date of Birth

Country of Birth

Child 2 Name

First

Middle

Last

Alien Number (USCIS Number or A#)

Date of Birth

Country of Birth

Child 3 Name

First

Middle

Last

Alien Number (USCIS Number or A#)

Date of Birth

Country of Birth

Child 4 Name

First

Middle

Last

Alien Number (USCIS Number or A#)

Date of Birth

Country of Birth

INADMISSIBILITY QUESTIONS

Have you ever been a member of, involved in, or in any way associated with any organiation, association, fund, foundation, party, club, society, or similar group in the US or in any other location in the world including any military service?

List the name(s) of organization(s), location(s), dates of membership, from and to, and the nature of the organization(s).

Have you ever been denied admission to the US?

Have you ever been denied a visa to the US?

Have you ever worked in the US without authorization?

Have you ever violated the terms or conditions of your nonimmigrant status?

Are you presently or have you ever been in removal, exclusion, rescission, or deportation proceedings?

Have you ever been issued a final order of exclusion, deportation, or removal?

Have you ever had a prior final order of exclusion, deportation, or removal reinstated?

Have you ever held lawful permanent resident status which was later rescinded?

Have you ever been granted voluntary departure by an immigration officer or an immigration judge but failed to depart within the allotted time?

Have you ever applied for any kind of relief or protection from removal, exclusion, or deportation?

Have you ever been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement?

Have you complied with the foreign residence requirement?

Have you been granted a waiver or has the Department of State issued a favorable waiver recommendation letter for you?

Have you ever been arrested, cited, charged, or detained for any reason by any law enforcement official?

Have you ever committed a crime of any kind even if you were not arrested, cited, charged with, or tried for that crime?

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?

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?

Have you ever been a defendant or the accused in a criminal proceeding including pre-trial diversion, deferred prosecution, deferred adjudication, or any withheld adjudication?

Have you ever violated, or aatempted or conspired to violate, any controlled substance law or regulation of a state, the US, or a foreign country?

Have you ever been convicted of two or more offenses, other than purely political offenses, for which the combined sentences to confinement were five years or more?

Have you ever illegally trafficked or benefited from the trafficking of any controlled substances, such as chemicals, illegal drugs, or narcotics?

Have you ever knowingly aided, abetted, assisted, conspired, or colluded in the illicit trafficking of any illegal narcotic or other controlled substances?

Are you the spouse, son, or daughter of a foreign national 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 five years, any financial or other benefit from the illegal activity of your spouse, parent, although you knew or reasonably should have known that the financial or other benefit resulted from the illicit activity of your spouse or parent?

Have you ever engaged in prostitution or are you coming to the US to engage in prostitution?

Have you ever directly or indirectly procured, or attempted to procure, or imported prostitutes or persons for the purpose of prostitution?

Have you ever received any proceeds or money from prostitution?

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 US?

Have you ever exercised immunity, diplomatic or otherwise, to avoid being prosecuted for a criminal offense in the US?

Have you ever, while serving as a foreign government official, been responsible for or directly carried out violations of religious freedoms?

Have you ever induced by force, fraud, or coercion, or otherwise been involved in, the trafficking of persons for commercial sex acts?

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.

Have you ever knowingly aided, abetted, assisted, conspired, or colluded with others in trafficking persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or slavery?

Are you the spouse, son, or daughter of a foreign national who engaged in the trafficking of persons and have received or obtained, within the last five years, any financial or other benefit from the illegal activity of your spouse, parent, although you knew or reasonably should have known that the financial or other benefit resulted from the illicit activity of your spouse or parent?

Have you ever engaged in money laundering or have you ever knowingly aided, assisted, conspired, or colluded with others in money laundering or do you seek to enter the US to engage in such activity?

Do you intend to engage in any activity that violates or evades any law relating to espionage, including spying, or sabotage in the US?

Do you intend to engage in any activity in the US that violates or evades any law prohibiting the export from the US of goods, technology, or sensitive information?

Do you intend to engage whose purpose includes opposing, controlling, or overthrowing the US government by force, violence, or other unlawful means while in the US?

Do you intend to engage in any activity that could endanger the welfare, safety, or security of the US?

Do you intend to engage in any other unlawful activity?

Are you engaged in or, upon your entry into the US, do you intend to engage in any activity that could have potentially serious adverse foreign policy consequences for the US?

Have you ever committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Have you ever participated in, or been a member of, a group or organization committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Have you ever recruited members or asked for money or things of value for a group or organization that committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Have you ever provided money, a thing of value, services or labor, or any other assistance or support for hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Have you ever received any type of military, paramilitary, or weapons training?

Do you intend to engage in hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Are you the spouse or child of an individual who ever committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Are you the spouse or child of an individual who ever participated in, or been a member of, a group or organization committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Are you the spouse or child of an individual who ever recruited members or asked for money or things of value for a group or organization that committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Are you the spouse or child of an individual who ever provided money, a thing of value, services or labor, or any other assistance or support for hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property?

Are you the spouse or child of an individual who ever received any type of military, paramilitary, or weapons training from a group or organization that committed, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use a weapon or explosive to harm another individual or cause substantial damage to property??

Have you ever assisted or participated in selling, providing, or transporting weapons to any person who, to your knowledge, used them against another person?

Have you ever worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons?

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 f weapon against any person or threatened to do so?

Have you ever served in, been a member of, assisted, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerilla group, militia, insurgent organization, or any other armed group?

Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party in the US or abroad?

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

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving torture or genocide?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving killing any person?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving intentionally and severely injuring any person?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in acts involving engaging in any kind of sexual contact or relations with any person who did not consent or was unable to consent, or was being forced or threatened?

Have you ever ordered, incited, called for, committed, assisted, helped with, or otherwise participated in limiting or denying any person's ability to exercise religious beliefs?

Have you ever recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group?

Have you ever used any person under 15 years of age to take part in hostilities, or to help or provide services to people in combat?

Have you received public assistance in the US from any source, including the US Government or any state, county, city, or municipality other than emergency medical treatment?

Are you likely to receive public assistance in the future in the US from any source, including the US Government or any state, county, city, or municipality other than emergency medical treatment?

Have you ever failed to refused to attend or to remain in attendance at any removal proceeding filed against you on or after April 1, 1997?

Do you believe you had reasonable cause?

Have you ever submitted fraudulent or counterfeit documentation to any US Government official to obtain or attempt to obtain any immigration benefit, including a visa or entry into the US?

Have you ever falsely claimed to be a US citizen in writing or in any other way?

Have you ever been a stowaway on a vessel or aircraft arriving in the US?

Have you ever knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or to try to enter the US illegally?

Are you under a final order of civil penalty for violating INA Section 274C for use of fraudulent documents?

Have you ever been excluded, deported, or removed from the US or have you ever departed the US on your own after having been ordered excluded, deported, or removed from the US?

Have you ever entered the US without being inspected and admitted or paroled?

Since April 1, 1997, have you been unlawfully present in the US for more than 180 days but less than a year, and then departed the US?

Since April 1, 1997, have you been unlawfully present in the US for one year or more and then departed the US?

Since April 1, 1997, have you ever reentered or attempted to reenter the US without being inspected and admitted or paroled after having been unlawfully present in the US for more than one year in the aggregate?

Since April 1, 1997, have you ever reentered or attempted to reenter the US without being inspected and admitted or paroled after having been deported, excluded, or removed from the US?

Do you plan to practice polygamy in the US?

Are you accompanying another foreign national who requires your protection or guardianship but who is inadmissible after being certified by a medical officer as being helpless from sickness, physical or mental disability, or infancy, as described in INA Section 232(c)?

Have you ever assisted in detaining, retaining, or withholding custody of a US citizen child outside the US from a US citizen who has been granted custody of the child?

Have you ever voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or regulation in the US?

Have you ever renounced US citizenship to avoid being taxed by the US?

Have you ever applied for exemption or discharge from training or service in the US armed forces or in the US National Security Training Corps on the ground that you are a foreign national?

Have you ever been relieved or discharged from such training or service on the ground that you are a foreign national?

Have you ever been convicted of desertion from the US armed forces?

Have you ever left or remained outside the US to avoid or evade training or service in the US armed forces in time of war or a period declared by the President to be a national emergency?

What was your nationality or immigration status immediately before you left?

Enter the Information of the Person Submitting This Questionnaire

Name *

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Adjustment of Status Questionnaire

For Applying For Permanent Residency

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