Official Federal Forms > US Citizenship And Immigration Services
Application For Family Unity Benefits I-817 - Official Federal Forms
| Application For Family Unity Benefits Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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OMB No. 1615-0005: Expires 02/28/2013 Department of Homeland Security U.S. Citizenship and Immigration Services I-817, Application for Family Unity Benefits For USCIS Use Only Receipt Returned START HERE - Type or print in black ink Part 1. Information About You (Person requesting Family Unity Benefits) Family Name (Last Name) Given Name (First Name) Full Middle Name Date Date Resubmitted Date Date of Birth (mm/dd/yyyy) A-Number (if any) U.S. Social Security No. (if any) Country of Birth Country of Citizenship Gender Male Female Home Address: Street Number and Name (include apartment number) City Date Reloc Sent Zip Code State Date Date Reloc Rec'd Date Mailing Address: (if different from home address) C/O: (In Care Of) City Daytime Phone Number (include area code) State Zip Code Date Applicant Interviewed on Remarks Part 2. Basis for Application 1. I am applying for family unity benefits because: (Check one box) A. B. C. I am the spouse of an alien who was legalized under section 245A of the INA, and we have been married since at least May 5, 1988. I am the spouse of an alien who was legalized as a Special Agricultural Worker under section 210 of the INA, and we have been married since at least December 1, 1988. As of May 5, 1988, I was the unmarried child under the age of 21 of an alien who was legalized under section 245A of the INA. I am currently the child, son, or daughter of the same parent. That parent is either a legalized alien or a naturalized U.S. citizen who was a legalized alien on or before May 5, 1988, and maintained such status until his or her naturalization. As of December 1, 1988, I was the unmarried child under 21 years of age of an alien who was legalized as a Special Agricultural Worker under section 210 of the INA. I am currently the child, son, or daughter of the same parent. That parent is either a legalized alien or a naturalized U.S. citizen who was a legalized alien on or before December 1, 1988, and maintained such status until his or her naturalization. I am the spouse of a legalized alien who adjusted under section 202 of the Immigration Reform and Control Act of 1986 (Cuban/Haitian Adjustment), and we have been married since at least May 5, 1988. As of May 5, 1988, I was the unmarried child under 21 years of age of an alien who adjusted under section 202 of the Immigration Reform and Control Act of 1986 (Cuban/Haitian Adjustment). I am currently the child, son, or daughter of the same parent. That parent is either a legalized alien or a naturalized U.S. citizen who was a legalized alien on or before May 5, 1988, and maintained such status until his or her naturalization. I am the spouse of an alien who is eligible for and has filed for adjustment under section 1504 of P. L. 106-554, the LIFE Act Amendments. I entered the United States before December 1, 1988, and was in the United States on that date. I am the unmarried child of an alien who is eligible for and has filed for adjustment pursuant to section 1504 of P. L. 106-554, the LIFE Act Amendments. I entered the United States before December 1, 1988, and was in the United States on that date. Action Block D. E. F. Initial Application Approved Denied Valid from: to: Request for Extension Approved Denied Valid from: to: To Be Completed by Attorney or Representative, if any Fill in box if G-28 is attached to represent the applicant. ATTY State License # G. H. Form I-817 (Rev. 02/28/12) Y American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Basis for Application (Continued) 2. I am requesting: (Check one box) Initial family unity benefits under section 301 of IMMACT 90. An extension of family unity benefits under section 301 of IMMACT 90. Initial family unity benefits under section 1504 of P. L. 106-554, the LIFE Act Amendments. 3. I am claiming relationship to: (Check one box) A legalized alien under section 301 of IMMACT 90. An alien who is eligible for and has filed for adjustment under section 1504 of P. L. 106-554, the LIFE Act Amendments. Part 3. Additional Information 1. At the time of your last entry into the United States, you: a. were inspected and admitted were inspected and paroled Current or most recent immigration status entered without inspection Date status expires (mm/dd/yyyy) Date continuous U.S. residence began (mm/dd/yyyy) b. Date of last arrival (mm/dd/yyyy) I-94, Arrival-Departure Document No. 2. Give the U.S. address where you lived on May 5, 1988 (sec. 245A/Cuban Haitian Adjustment) or December 1, 1988 (sec. 210/LIFE Act) Street number and name (Include apartment number) City State Zip Code 3. Have you ever applied before for the Family Unity Program? Name under which you applied: No Yes (If "Yes," provide the following information) City and state where application was filed Date filed (mm/dd/yyyy) USCIS action taken on case: Approved Denied 4. If separate applications for family unity benefits are being submitted at this time for other relatives, give the following information: Family Name (Last Name) First Name Middle Name Relationship A-Number 5. List all other names you have used including maiden name. 6. List all absences from the United States since May 5, 1988 or December 1, 1988, as appropriate, or since the approval of your last family unity application (Form I-817), whichever date is later. Date of Departure (mm/dd/yyyy) Date of Return (mm/dd/yyyy) Date of Departure (mm/dd/yyyy) Date of Return (mm/dd/yyyy) NOTE: If you need more space to complete an answer, use a separate sheet of paper. Write your name and A-Number, if you have one, at the top of each sheet and indicate the number of the item that refers to your answer. Form I-817 Form (Rev. 02/28/12) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Additional Information (Continued) 7. List all residences in the United States since May 5, 1988 or December 1, 1988, as appropriate, or since the approval of your last Family Unity application (Form I-817), whichever date is later. Street Number and Name (Include Apartment #) City State Zip Code Dates of Residence From From From From From From 8. Do you have or have you ever had: a. A communicable disease of public health significance (including chancroid, gonorrhea, granuloma inguinal, humanimmunodeficiency virus (HIV) infection, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, or active tuberculosis)? b. A physical or mental disorder and behavior associated with the disorder which has posed or may pose a threat to the prop
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