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A. Relationship
(You are the petitioner; your relative is the beneficiary)

1. I am filing this petition for my: Husband/Wife
Parent
Brother/Sister
Child
2. Are you related by adoption? Yes
No
3. Did you gain permanent residence through adoption? Yes
No

B. Information about you

1. Family Name (Family name in CAPS)
Given Name
Middle Initial
E-mail
Phone
2. Address (Number and Street)
(Apt.No.)
(Town or City)
(State/Country)
(Zip/Postal Code)
3. Place of Birth (Town or City)
(State/Country)
4. Date of Birth (Month/Day/Year)
5. Gender Male
Female
6. Marital Status Married
Single
Widowed
Divorced
7. Other Names Used (including maiden name)
8. Date and Place of Present Marriage (if married)
9. Social Security Number (if any)
10. Alien Registration Number
11. Name(s) of Prior Husband(s)/Wive(s)
12. Date(s) Marriage(s) Ended
13. If you are a U.S. citizen, complete the following:
My citizenship was acquired through (check one):
Birth in the U.S.
Naturalization. Give certificate number and date and place of issuance.
        
Parents. Have you obtained a certificate of citizenship in your own name?
        Yes. Give certificate number, date and place of issuance. No
        
14a. If you are a lawful permanent resident alien, complete the following:
Date and place of admission for, or adjustment to, lawful permanent residence and class of admission.
14b. Did you gain permanent resident status through marriage to a United States citizen or lawful permanent resident?
Yes
No

C. Information about your relative

1. Name (Family name in CAPS)
(First)
(Middle)
2. Address (Number and Street)
(Apt.No.)
(Town or City)
(State/Country)
(Zip/Postal Code)
3. Place of Birth (Town or City)
(State/Country)
4. Date of Birth (Month/Day/Year)
5. Gender Male
Female
6. Marital Status Married
Single
Widowed
Divorced
7. Other Names Used (including maiden name)
8. Date and Place of Present Marriage (if married)
9. Social Security Number (if any)
10. Alien Registration Number
11. Name(s) of Prior Husband(s)/Wive(s)
12. Date(s) Marriage(s) Ended
13. Has your relative ever been in the U.S.? Yes No
14. If your relative is currently in the U.S., complete the following:
He or she arrived as a:		 (visitor, student, stowaway, without inspection, etc.)
Date arrived (Month/Day/Year)
Date authorized stay expired, or will expire, as shown on Form I-94 or I-95
15. Name and address of present employer (if any)
Date this employment began (Month/Day/Year)
16. Has your relative ever been under immigration proceedings?
No Yes      Where       When
Removal Exclusion/Deportation Recission Judicial Proceedings

INITIAL RECEIPT
RESUBMITTED
RELOCATED: Rec'd
Sent
COMPLETED: Appv'd
Denied
Ret'd

17. List husband/wife and all children of your relative.
(Name)
(Relationship)
(Date of Birth)
(Country of Birth)

(Name)
(Relationship)
(Date of Birth)
(Country of Birth)

(Name)
(Relationship)
(Date of Birth)
(Country of Birth)

(Name)
(Relationship)
(Date of Birth)
(Country of Birth)

(Name)
(Relationship)
(Date of Birth)
(Country of Birth)

18. Address in the United States where your relative intends to live.
(Street Address)
(Town or City)
(State)

19. Your relative's address abroad (Include street, city, province and country)
Phone Number (if any)
20. If your relative's native alphabet is other than Roman letters, write his or her name and foreign address in the native alphabet.
(Name)
Address (Include street, city, province and country):
21. If filing for your husband/wife, give last address at which you lived together.
(Include street, city, province, if any, and country):
From:      (Month)      (Year)
To:           (Month)      (Year)
22. Complete the information below if your relative is in the United States and will apply for adjustment of status.
Your relative is in the United States and will apply for adjustment of status to that of a lawful permanent resident at the office of the US Citizenship and Immigration Services in:
(City):
(State):
If your relative is not eligible for adjustment of status, he or she will apply for a visa abroad at the American consular post in:
(City):
(Country):
NOTE: Designation of an American embassy or consulate outside the country of your relative's last residence does not guarantee acceptance for processing by that post. Acceptance is at the discretion of the designated embassy or consulate.

D. Other information

1. If separate petitions are also being submitted for other relatives, give names of each and relationship.
2. Have you ever filed a petition for this or any other alien before? Yes No
If "Yes," give name, place and date of filing and result.

WARNING: USCIS investigates claimed relationships and verifies the validity of documents. USCIS seeks criminal prosecutions when family relationships are falsified to obtain visas.

PENALTIES: By law, you may be imprisoned for not more than five years or fined $250,000, or both, for entering into a marriage contract for the purpose of evading any provision of the immigration laws. In addition, you may be fined up to $10,000 and imprisoned for up to five years, or both, for knowingly and willfully falsifying or concealing a material fact or using any false document in submitting this petition.

YOUR CERTIFICATION: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Furthermore, I authorize the release of any information from my records which the US Citizenship and Immigration Services needs to determine eligibility for the benefit that I am seeking.
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