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Health And Human Services Statistical Data For Refugee-Asylee Adjusting Status I-643 - Official Federal Forms
| Health And Human Services Statistical Data For Refugee-Asylee Adjusting Status Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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OMB No: 1615-0070; Expires 01/31/2015 Department of Homeland Security U.S. Citizenship and Immigration Services I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status Print or type in blue or black ink. Last (Family) First (Given) 1. Name: Country of Birth: Native Language: Current Address: (Number, Street, and Apartment No.) Middle Today's Date: (mm/dd/yyyy) Country of Citizenship/Nationality: Date of Birth (mm/dd/yyyy) Telephone Number (with area code) Alien Registration Number: ASocial Security Number: Cellphone Number (with area code) (City) (List most recent first) (State) (Zip Code) 2. My three most recent cities of residence in the United States have been: City or Town State From (mm/dd/yyyy) To (mm/dd/yyyy) Present 3. There are Name (Self) of whom are employed. members of the household, Relationship Gender Date of Birth Country of Alien Number (mm/dd/yyyy) to Me M/F Birth (Self) (Please use another sheet(s) if needed) Currently Employed? Attending School? Yes No Yes No 4. My employment since entering the United States has been: (List most recent first) Location To From Company Name City, State (mm/dd/yyyy) (mm/dd/yyyy) Job Title Check One Wage Per Part Full Hour Time Time My major occupation or profession before coming to the United States was: 5. My education before coming to the United States was: Grades 1-8 Some high school High school diploma Technical school Technical school certificate Some university University diploma Graduate studies Professional training Graduate degree (Check all that apply) My knowledge of English was acquired by: (Check all that apply) Use in another country Training in the U.S. Use in the U.S. Training in another country Training in refugee camp Other (Please explain): (Check one) 6. I have had the following training or education in the U.S. Type of Training/Education High School College Technical/Vocational Course of Study (Check all that apply) 7. English Language Skills: Speaking Reading Writing None Good None Good None A Few Words A Few Words A Few Words Check If Still Attending Check If Completed Fair Fair Fair Other (specify): Good 8. Since in the United States, list as many types of public assistance (excluding emergency medical treatment) that you have received or someone has received on your behalf. Please include public assistance received from the U.S. Government or any State, county, city, or municipality. Public Assistance Cash assistance (Welfare) Food Stamps SSI Form I-643 (01/08/13) Y Page 1 American LegalNet, Inc. www.FormsWorkFlow.com From (mm/yyyy) To (mm/yyyy) Public Assistance Medical assistance Other (specify): From (mm/yyyy) To (mm/yyyy)
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