Adjustment of Status Intake Form

Adjustment of Status Intake Form

Please provide your personal and contact information, along with your address history for the past 5 years.
Immigration Security Questions
Have you ever been arrested or detained?
Have you ever violated immigration laws or status conditions?
Have you ever been deported, removed, or denied entry?
Have you ever worked without authorization?
Have you ever committed fraud or misrepresentation?
Have you ever claimed U.S. citizenship when you were not a citizen?
Have you ever been denied a visa or other immigration benefit?
Have you ever engaged in criminal or terrorist activity?
If yes to any question above, please explain.
Full Legal Name

First NameMiddle NameLast Name
Other Names Used (including maiden names, nicknames, aliases)
Date of Birth

MonthDayYear
Date
City and Country of Birth
Country of Citizenship or Nationality
Gender

Other
Marital Status
Alien Registration Number (A-Number)
USCIS Online Account Number
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is your mailing address different from your current physical address?
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Address History (Last 5 Years)
Passport Number
Passport Country of Issuance
Passport Expiration Date

MonthDayYear
Date
Date of Last Entry into the United States

MonthDayYear
Date
Place of Entry
Visa Type
I-94 Number
Expiration Date of Stay

MonthDayYear
Date
Did you enter with inspection?
Have you overstayed your visa?
Category of Application
Select the basis that best applies to your application.
Name of Petitioner or Sponsor
Enter the name as it appears on the petition, if applicable.
Relationship to Petitioner
For example: spouse, parent, employer, or relative.
Receipt Number of Underlying Petition
Enter the receipt number from USCIS, if available.
Priority Date

MonthDayYear
Date
Father's Full Name
Father's Country of Birth
Father's Date of Birth

MonthDayYear
Date
Mother's Full Name
Mother's Country of Birth
Mother's Date of Birth

MonthDayYear
Date
Marital History
Spouse Date of Birth

MonthDayYear
Date
Spouse Immigration Status
Number of Prior Marriages
Current Employer Name
Current Employer Address
Current Job Title
Current Job Start Date

MonthDayYear
Date
Sponsor Full Name

First NameMiddle NameLast Name
Sponsor Relationship to Applicant
Sponsor Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Sponsor Annual Income
Sponsor Household Size
Travel History
Date Left

MonthDayYear
Date
Date Returned

MonthDayYear
Date
Countries Visited
Have you ever filed any prior immigration applications?
Have any prior immigration applications ever been denied?
Have you ever had immigration court history?
Have you ever been subject to a removal order?
Should be Empty:

Adjustment of Status Intake Form

Immigration Security Questions

Travel History