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Part A.I. Information About You

1. Alien Registration Number(s) (A-Number) (if any)

2. U.S. Social Security Number (if any)

3. USCIS Online Account Number (if any)

4. Complete Last Name

5. First Name

6. Middle Name

7. What other names have you used (include maiden name and aliases)?

8. Residence in the U.S. (where you physically reside)

Street Number and Name

Apt. Number

City

State

Zip Code

Telephone Number

9. Mailing Address in the U.S. (if different than the address in Item Number 8)

In Care Of (if applicable):

Telephone Number

Street Number and Name

Apt. Number

City

State

Zip Code

10. Gender:

Male

Female

11. Marital Status:

Single

Married

Divorced

Widowed

12. Date of Birth (mm/dd/yyyy)

13. City and Country of Birth

14. Present Nationality (Citizenship)

15. Nationality at Birth

16. Race, Ethnic, or Tribal Group

17. Religion

18. Check the box, a through c, that applies:

a. I have never been in Immigration Court proceedings.

b. I am now in Immigration Court proceedings.

c. I am not now in Immigration Court proceedings, but I have been in the past.

19. Complete 19 a through c.

a. When did you last leave your country? (mm/dd/yy)

b. What is your current I-94 Number, if any?

c. List each entry into the U.S. beginning with your most recent entry.

List date (mm/dd/yyyy), place, and your status for each entry.

(Attach additional sheets as needed)

Date

Place

Status

Date Status Expires

Date

Place

Status

Date

Place

Status

20. What country issued your last passport or travel document?

21. Passport Number

Travel Document Number

22. Expiration Date (mmddyy)

23. What is your native language (include dialect, if applicable)?

24. Are you fluent in English?

Yes

No

25. What other languages do you speak fluently?

Assistant