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BENEFICIARY QUESTIONNAIRE I-485 (ADJUSTMENT OF STATUS)

This form will take an estimate of 20 minutes to accomplish. You cannot save the form and continue later. If you want a PDF format of this questionnaire please email support@iapnewstart.com. If the form does not submit after you finished the questionnaire, please go over your answers make sure you have not missed a required question.

Family -based category Immediate relative of a US citizen, Form I-130 Other relative of a US citizen or relative of a lawful permanent resident under the family-based preference categories, Form I-130 Person admitted to the US as a fiancé(e) or child of a fiancé(e) of a US citizen, Form I-129F(K1-K2 Nonimmigrant) Widow or widower of a US citizen, For I-360 VAWA self-petitioner, Form I-360

Employment-based Alien worker, Form I-360 Alien enterpreneur, Form I-526

Special Immigrant Religious worker, Form I-360 Special immigrant juvenile, Form I-360 Certain Afghan or Iraqi national, Form I-360 Certain international broadcaster, Form I-360 Certain G-4 international orgranization or family member or NATO-6 employee or family member, Form I-360

Asylee or Refugee Asylum status (INA section 208), Form I-589 or Form I-730 Refugee status (INA section 207), Form I-590 or Form I-730

Human Trafficking Victim or Crime Victim Human trafficking victim (T Nonimmigrant), Form I-914 or derivative family member, Form I-914A Crime victim (U Nonimmigrant), Form I-918, derivative family member, Form I-918A, or qualifying family member, Form I-929

INFORMATION ABOUT YOU

Email Address *

Telephone Number *

Family Name *

Given Name *

Middle Name *

Other names you used since birth :Family Name

Given Name *

Middle Name *

Reason for name change

Your date of birth * date_range

Gender * Male Female

City/ Town of Birth *

Country of birth *

Country of citizenship *

Alien Registration Number (if any)

USCIS Online Account Number ( if any)

Do you want SSA to issue a Social Security card? Yes No

If you answered “Yes,” provide the information

Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? Yes No

U.S Mailing Address: In Care of Name (C/O if any)

Street Number and Name *

Apartment #, Suite # or Floor # (if applicable)

City/ Town *

State and ZIP Code *

Alternate and/or safe mailing address

Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? * Yes No

If you answered “Yes,Provide your U.S. Social Security Number (SSN).

Do you want the SSA to issue you a Social Security card? * Yes: I authorize disclosure of information from this application to the SSA as required for the purpose of assigning me an SSN and issuing me a Social Security Card. No

IMMIGRATION HISTORY

Passport Number Used at Last Arrival *

Travel document Used at Last Arrival *

Expiration Date of this Passport or Travel Document * date_range

Date of issue of this Passport or Travel Documeny * date_range

Country that Issued this Passport or Travel Document

Nonimmigrant Visa Number from this Passport (if any)

Place of Last Arrival into the United States *

Date of Arrival * date_range

When you last arrived in the United States were you * Was inspected at a port of entry and admitted as (for example, exchange visitor; visitor, waived through; temporary worker; student) Was inspected at a port of entry and paroled as (for example, humanitarian parole, Cuban parole): Came into the United States without admission or parole Other:

Form I-94 Arrival-Departure Record Number: *

Expiration Date of Authorized Stay Shown on Form I-94 *

Provide your name exactly as it appears on your Form I-94 (if any) *

PRINCIPAL APPLICANT

Receipt Number of Underlying Petition (if any) *

Priority Date date_range

If you are the DERIVATIVE APPLICANT: provide the following information for the PRINCIPAL applicant

Family Name *

Given Name *

Middle Name *

Date of birth * date_range

Receipt Number of Principal's Underlying Petition (if any)

Priority Date of Principal Applicant's Underlying Petition (if any) date_range

Have you ever applied for an immigrant visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad? Yes No

If Yes: Location of U.S. Embassy or U.S. Consulate

Decision (for example, approved, refused, denied, withdrawn)

Date of decision date_range

Provide physical addresses for everywhere you have lived during the last five years, whether inside or outside the United States. Provide your current address first. *

Provide physical address 2

Provide physical address 3

EMPLYOMENT HISTORY: Provide the most recent employment first *

Employer 1 (current or most recent) *

Employer 1 address

Your occupation *

Start date * date_range

End Date date_range

Employer 2 *

Employer 2 address

Your occupation *

Start date * date_range

End Date date_range

INFORMATION ABOUT YOUR PARENT 1 NAME OF PARENT

Date of Birth * date_range

City/ Town of birth *

Country of birth *

Gender * Male Female

Current City or Town of Residence (if living

NAME OF PARENT 2

Date of Birth * date_range

City/ Town of birth *

Country of birth *

Gender * Male Female

Current City or Town of Residence (if living

INFORMATION ABOUT YOUR CURRENT MARRIAGE

Current Spouse

A-number If applicable

Current Spouse's Date of Birth date_range

Current Spouse's PLACE OF BIRTH: City/Town+ State or Province+Country

Date of Marriage to Current Spouse date_range

PLACE OF MARRIAGE: City/Town+ State or Province+Country

Is your current spouse applying with you? Yes No

PRIOR MARRIAGES: If you have been married before, whether in the United States or in any other country, provide the following information about your prior spouse

Prior Spouse's Legal Name (provide family name before marriage)

Prior Spouse's Date of Birth date_range

Prior Spouse's PLACE OF BIRTH: City/Town+ State or Province+Country

Date of Marriage to Prior Spouse date_range

PLACE OF MARRIAGE: City/Town+ State or Province+Country

Prior Spouse 3: Name before marriage+ date of birth+ Place of birth+Date of marriage+place of marriage

INFORMATION ABOUT YOUR CHILDREN Indicate the total number of ALL living children

CHILD 1: Family Name+ Given name + Middle Name

Date of Birth date_range

Country of Birth

CHILD 2: Family Name+ Given name + Middle Name

Date of Birth date_range

Country of Birth

CHILD 3: Family Name+ Given name + Middle Name

Date of Birth date_range

Country of Birth

CHILD 4: Family Name+ Given name + Middle Name

Date of Birth date_range

Country of Birth

BIOGRAPHIC INFORMATION: Ethnicity (Select only ONE box) * Hispanic or Latino Not Hispanic or Latino

Height in feet and inches *

Weight in pounds (lbs) *

PLACE ADDITIONAL INFORMATION HERE

END OF QUESTIONNAIRE: