Form I 90 SCP2700KBL
User Manual: SCP2700KBL
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Application to Replace Permanent Resident Card Department of Homeland Security U.S. Citizenship and Immigration Services Applicant Interviewed USCIS Form I-90 OMB No. 1615-0082 Expires 07/31/2019 Receipt Action Block Date: Class of Admission For USCIS Use Only Remarks ► START HERE - Type or print in black ink. Part 1. Information About You 1. Alien Registration Number (A-Number) Mailing Address (USPS ZIP Code Lookup) 6.a. In Care Of Name A2. USCIS Online Account Number (if any) ► 6.b. Street Number and Name 6.c. Your Full Name NOTE: Your card will be issued in this name. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. Apt. Ste. Flr. 6.d. City or Town 6.e. State 6.f. ZIP Code 6.g. Province 6.h. Postal Code 6.i. Country Has your name legally changed since the issuance of your Permanent Resident Card? Yes (Proceed to Item Numbers 5.a. - 5.c.) Physical Address No (Proceed to Item Numbers 6.a. - 6.i.) Provide this information only if different than mailing address. N/A - I never received my previous card. (Proceed to Item Numbers 6.a. - 6.i.) 7.a. Street Number and Name Provide your name exactly as it is printed on your current Permanent Resident Card. NOTE: Attach all evidence of your legal name change with this application. 7.b. Apt. Flr. 7.c. City or Town 7.d. State 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 7.f. 5.c. Middle Name 7.h. Country Form I-90 02/27/17 N Ste. 7.e. ZIP Code Province 7.g. Postal Code Page 1 of 7 Part 1. Information About You (continued) Reason for Application (Select only one box) Additional Information Section A. (To be used only by a lawful permanent resident or a permanent resident in commuter status.) 8. Gender Male 9. Date of Birth (mm/dd/yyyy) 10. City/Town/Village of Birth 11. Female My previous card has been lost, stolen, or destroyed. 2.b. My previous card was issued but never received. 2.c. My existing card has been mutilated. 2.d. My existing card has incorrect data because of Department of Homeland Security (DHS) error. (Attach your existing card with incorrect data along with this application.) 2.e. My name or other biographic information has been legally changed since issuance of my existing card. 2.f. My existing card has already expired or will expire within six months. 2.g.1. I have reached my 14th birthday and am registering as required. My existing card will expire AFTER my 16th birthday. (See NOTE below for additional information.) 2.g.2. I have reached my 14th birthday and am registering as required. My existing card will expire BEFORE my 16th birthday. (See NOTE below for additional information.) Country of Birth Mother's Name 12. 2.a. Given Name (First Name) Father's Name 13. Given Name (First Name) 14. Class of Admission 15. Date of Admission (mm/dd/yyyy) 16. U.S. Social Security Number (if any) NOTE: If you are filing this application before your 14th birthday, or more than 30 days after your 14th birthday, you must select reason 2.j. However, if your card has expired, you must select reason 2.f. ► Part 2. Application Type 2.h.1. I am a permanent resident who is taking up commuter status. NOTE: If your conditional permanent resident status (for example: CR1, CR2, CF1, CF2) is expiring within the next 90 days, then do not file this application. (See the What is the Purpose of This Application section of the Form I-90 Instructions for further information.) 2.h.1.a. My Port-of-Entry (POE) into the United States will be: City or Town and State 2.h.2. I am a commuter who is taking up actual residence in the United States. My status is (Select only one box): 1.a. Lawful Permanent Resident (Proceed to Section A.) 2.i. 1.b. Permanent Resident - In Commuter Status (Proceed to Section A.) I have been automatically converted to lawful permanent resident status. 2.j. I have a prior edition of the Alien Registration Card, or I am applying to replace my current Permanent Resident Card for a reason that is not specified above. 1.c. Conditional Permanent Resident (Proceed to Section B.) Form I-90 02/27/17 N Page 2 of 7 Biographic Information Part 2. Application Type (continued) Section B. (To be used only by a conditional permanent resident.) 3.a. My previous card has been lost, stolen, or destroyed. 3.b. My previous card was issued but never received. 3.c. My existing card has been mutilated. 3.d. My existing card has incorrect data because of DHS error. (Attach your existing permanent resident card with incorrect data along with this application.) 3.e. My name or other biographic information has legally changed since the issuance of my existing card. 6. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 7. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 8. Height 9. Weight 10. Eye Color (Select only one box) Feet Inches Part 3. Processing Information 1. 2. Location where you applied for an immigrant visa or adjustment of status: Location where your immigrant visa was issued or USCIS office where you were granted adjustment of status: 11. Complete Item Numbers 3.a. and 3.a1. if you entered the United States with an immigrant visa. (If you were granted adjustment of status, proceed to Item Number 4.) Pounds Black Gray Blue Brown Green Hazel Maroon Pink Unknown/Other Hair Color (Select only one box) Bald (No hair) Brown Sandy Black Gray White Blond Red Unknown/Other 3.a. Destination in the United States at time of admission 3.a.1. Port-of-Entry where admitted to the United States: City or Town and State 4. Have you ever been in exclusion, deportation, or removal proceedings or ordered removed from the United States? Yes 5. No Since you were granted permanent residence, have you ever filed Form I-407, Abandonment by Alien of Status as Lawful Permanent Resident, or otherwise been determined to have abandoned your status? Yes No NOTE: If you answered "Yes" to Item Numbers 4. or 5. above, provide a detailed explanation in the space provided in Part 8. Additional Information. Form I-90 02/27/17 N Part 4. Accommodations for Individuals with Disabilities and/or Impairments (Read the information in the Form I-90 Instructions before completing this part.) NOTE: If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 1. Are you requesting an accommodation because of your disabilities and/or impairments? Yes No If you answered "Yes," select any applicable boxes: 1.a. I am deaf or hard of hearing and request the following accommodation (If you are requesting a sign-language interpreter, indicate for which language (for example, American Sign Language)): Page 3 of 7 Part 4. Accommodations for Individuals with Disabilities and/or Impairments (continued) 1.b. 1.c. Applicant's Contact Information I am blind or have low vision and request the following accommodation: 3. Applicant's Daytime Telephone Number 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any) Applicant's Certification I have another type of disability and/or impairment (Describe the nature of your disability and/or impairment and the accommodation you are requesting): Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the immigration benefit I seek. I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. Part 5. Applicant's Statement, Contact Information, Certification, and Signature I understand that USCIS will require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, I will be required to sign an oath reaffirming that: NOTE: Read the Penalties section of the Form I-90 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. 1.b. The interpreter named in Part 6. read to me every question and instruction on this application and my answer to every question in 1) I reviewed and provided or authorized all of the information in my application; 2) I understood all of the information contained in, and submitted with, my application; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct. , Applicant's Signature a language in which I am fluent and I understood everything. 2. 6.a. Applicant's Signature (sign in ink) At my request, the preparer named in Part 7., , prepared this application for me based only upon information I provided or authorized. Form I-90 02/27/17 N 6.b. Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application. Page 4 of 7 Part 6. Interpreter's Contact Information, Certification, and Signature Interpreter's Signature 7.a. Interpreter's Signature (sign in ink) Provide the following information about the interpreter. Interpreter's Full Name 7.b. Date of Signature (mm/dd/yyyy) 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name Interpreter's Mailing Address 1.a. Preparer's Family Name (Last Name) 3.a. Street Number and Name 1.b. Preparer's Given Name (First Name) 3.b. Apt. Ste. Flr. 2. 3.c. City or Town 3.d. State 3.f. Preparer's Business or Organization Name (if any) 3.e. ZIP Code Province Preparer's Mailing Address 3.g. Postal Code 3.a. Street Number and Name 3.h. Country 3.b. Apt. Ste. Flr. 3.c. City or Town Interpreter's Contact Information 3.d. State 4. Interpreter's Daytime Telephone Number 3.f. 5. Interpreter's Mobile Telephone Number (if any) 3.e. ZIP Code Province 3.g. Postal Code 3.h. Country 6. Interpreter's Email Address (if any) Preparer's Contact Information Interpreter's Certification 4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Telephone Number (if any) 6. Preparer's Email Address (if any) I certify, under penalty of perjury, that: I am fluent in English and , which is the same language provided in Part 5., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer. Form I-90 02/27/17 N Page 5 of 7 Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant (continued) Preparer's Statement 7.a. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. 7.b. I am an attorney or accredited representative and my representation of the applicant in this case does not extend beyond the extends preparation of this application. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8.a. Preparer's Signature (sign in ink) 8.b. Date of Signature (mm/dd/yyyy) Form I-90 02/27/17 N Page 6 of 7 5.a. Page Number Part 8. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Include your name and A -Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 5.b. Part Number 5.c. Item Number 6.b. Part Number 6.c. Item Number 7.b. Part Number 7.c. Item Number 5.d. Your Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 6.a. Page Number A3.a. Page Number 3.b. Part Number 3.c. Item Number 6.d. 3.d. 7.a. Page Number 4.a. Page Number 4.b. Part Number 4.c. Item Number 7.d. 4.d. Form I-90 02/27/17 N Page 7 of 7
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