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Page 1

Adjustment of Status Questionnaire

Part I, Biographic and Employment Data

Estimated Completion Time:

Part I, Biographic and Employment data: 45-75 minutes

Part II, Additional Eligibility Data: 20-30 minutes

This questionnaire requires detailed family, employment, and immigration history for you and any dependents applying with you. We recommend gathering vital records (e.g., passports, birth certificates, immigration records) before starting the questionnaire.

This questionnaire contains two "Parts." You must complete and submit Part I before you may proceed to Part II.

This questionnaire may be completed in more than one session. To save your work and end your session, click "Save my progress and resume later" at the top of the form. Then, carefully enter your email address and a unique password. To resume completing your questionnaire, click the link provided in the Initiation email you received from our office, and click "Resume a previously saved form." You will be prompted to enter the email address and password you provided previously.

"Save" often. Even if you are not ready to end your session, we recommend following the above steps frequently to save your questionnaire.

You must complete and submit this form within 30 days of starting it. After 30 days, incomplete questionnaires are deleted.

Page 2

Sponsoring Employer

Case Number

Copy the Case Number provided in the initiation email here.

Biographic Information

Employee ID

Last Name (as in passport)

Given Name(s) (as in passport)

Email (use email address assigned by your employer)

Gender

Maiden Name

Last Name before marriage. If none, state "None"

Date of Birth

mm/dd/yyyy

City/Town/Village of Birth

State or Province of Birth

Country of Birth

Country of Citizenship

Primary Phone (U.S.)

10 Digits (no spaces no dashes)

Ethnicity

Race

Eye Color

Hair Color

Height (feet)

Height (inches)

Weight (in lbs)

Marital Status

Spouse Applying for Permanent Residence (Green Card) with you?

YesNo

Any prior marriage?

YesNo

How many times have you been married (include your current spouse, annulled marriages, and marriages to the same person)?

Do you have any children?

Yes

How many living children do you have (include adult sons and daughters, biological, legally adopted, and step children)?

Do you or any of your dependents plan to travel outside the U.S. in the next six (6) months?

YesNo

Is your spouse a current member of the U.S. armed forces or U.S. Coast Guard?

YesNo

Please explain

Residential Address History

List where you resided for the last five (5) years below, starting with your current address in the U.S.

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this current address From

Add another address?

YesNo

Residential Addresses - 2

Street Name and Number

Apartment Number

City

State/Province

Zip/Pin Code

Country

Dates at this address

From

Add another address?

YesNo

Residential Addresses - 3

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

Add another address?

YesNo

Residential Addresses - 4

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

To (Year)

Add another address?

YesNo

Residential Addresses - 5

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

Add another address?

YesNo

Residential Addresses

Click "Add Another" to add additional addresses.

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

Non-U.S. Addresses

List your permanent Non-U.S. Address

Street Name and Number (of Current Non-U.S. Residence)

Apartment No.

City

State/Province

Zip/Pin Code

Country

Dates at this address

From

______________________________________________________________________________________

Is your last non-U.S. Address where you resided for more than 1 year the same as above?

YesNo

Street Name and Number of your last Non-US residence of more than 1 year

Apartment No.

City

State/Province

Zip/Pin Code

Country

Dates at this address

From

Did your spouse also reside at all of these addresses during the dates listed?

Parents' Information

Father's Last Name

Father's First Name

Father's Date of Birth

Please enter in (mm/dd/yyyy) format. If unknown, please enter "unknown"

Father's City of Birth

If unknown, state "unknown"

Father's Country of Birth

If unknown, state "unknown"

Father's City of Residence

If unknown, state "unknown"

Father's Country of Residence

If deceased, please enter "Deceased"

Mother's Maiden Name

Last Name before marriage. Note: If your mother's full name changed after marriage, record her full maiden (before marriage) name in this field.

Mother's First Name

If your mother's FIRST name changed after marriage, record her first name before marriage in this field.

Mother's Date of Birth

Please enter in (mm/dd/yyyy) format. If unknown, please enter "unknown"

Mother's City of Birth

If unknown, state "unknown"

Mother's Country of Birth

If unknown, state "unknown"

Mother's City of Residence

If deceased, please enter "Deceased"

Mother's Country of Residence

If deceased, please enter "Deceased"

Page 3

U.S. Immigration Information

Current Status

Date of Last Arrival

City or Town of Last Entry

Record the CITY and STATE where you were inspected by U.S. Immigration, not your final U.S. destination

State of Last Entry

I-94 Number

11 digits (include leading zero, if applicable)

Date I-94 Expires

If you have received an I-797 approval notice since your last U.S. entry, use the I-94 expiration at the bottom of your I-797.

In what status did you last enter the U.S.?

SSN

9 digits (no dashes, no spaces)

Alien Number (if any)

9 digits (no dashes or spaces)

Consulate of Visa Issuance

Record this information from your most recent visa in your passport, even if the visa is expired.

Nonimmigrant Visa Number

The visa number (usually 8 characters) can be found on your visa in red, located towards the bottom right side of the visa. Please DO NOT put the "Control Number" in this field.

Date Visa Issued

Record this information from your most recent visa in your passport, even if the visa is expired.

Have you ever filed Form I-485?

Yes

Have you ever applied for an Immigrant Visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad?

Yes

Location of U.S. Embassy or U.S. Consulate

City

Country

Decision

Date of Decision

Have you ever applied for Employment Authorization (EAD) before?

Yes

EAD Information

Answer the following questions about the most recent Employment Authorization Document (EAD) you received, even if it has expired. Do not enter information about a pending EAD application here.

Which Service Center

Validity Date(s)

Result

Passport Number

Expiration Date

mm/dd/yyyy

Country of Issuance

I.e., the country named on the cover of your passport.

Page 4

Address of your current U.S. employer

Name of Current Employer

Job Title

Formal corporate designation, not project role

Date employment started

Street Number and Name

Employer's US headquarters

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Province

Zip/Postal Code

Country

Address of your most recent Non-U.S. employment

Non U.S. Employer

Record the full legal name (e.g. Acme Consulting, Ltd.)

Non U.S. Job Title

Formal corporate designation, not project role

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Province

Zip/Postal Code

Country

From

Is the date you entered above more than five years from Today (the date you are completing this questionnaire)?

Employment History

Excluding your above-listed employment details, list your older employment history in the fields below. Click "Add Another" to add additional jobs. Your total employment history (in the above sections and this section) should cover your last five years of employment. Note: List your employment with related companies separately (e.g. Acme Technologies, Acme Computer Systems).

Previous Employer Name

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Provine

Zip/Postal Code

Country

From

Add Another Employment History?

YesNo

Employment History

Previous Employer Name

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Provine

Zip/Postal Code

Country

From

Add Another Employment History?

YesNo

Employment History

Previous Employer

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Provine

Zip/Postal Code

Country

From

Add Another Employment History?

YesNo

Employment History

Previous Employer Name

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Provine

Zip/Postal Code

Country

From

Page 5

Previous Spouse's (1) Biographic Data

Last Name

For wife, give maiden name

Given Name(s)

Gender

MaleFemale

Date of Birth

mm/dd/yyyy

City of Marriage

State of Marriage

Country of Marriage

Date of Marriage

mm/dd/yyyy

City of Termination of Marriage

State of Termination of Marriage

Country of Termination of Marriage

Date of Termination of Marriage

mm/dd/yyyy

Add another?

YesNo

Previous Spouse's (2) Biographic Data

Last Name

For wife, give maiden name

Given Name(s)

Gender

MaleFemale

Date of Birth

mm/dd/yyyy

City of Marriage

State of Marriage

Country of Marriage

Date of Marriage

mm/dd/yyyy

City of Termination of Marriage

State of Termination of Marriage

Country of Termination of Marriage

Date of Termination of Marriage

mm/dd/yyyy

Page 6

Information about your spouse

Spouse's Biographic Data

Last Name (as in passport)

Given Name(s) (as in passport)

Date of Birth

mm/dd/yyyy

City/Town/Village of Birth

State or Province of Birth

Country of Birth

Country of Citizenship

Gender

Maiden Name

Last Name before marriage. If none, state "None"

Relationship

City of Marriage

State of Marriage

Country of Marriage

Date of Marriage

mm/dd/yyyy

Any prior marriage?

YesNo

Primary Phone (U.S.)

Ethnicity

Race

Eye Color

Hair Color

Height (feet)

Height (inches)

Weight (in lbs)

Spouse's Residential History

List where your spouse resided for the last five (5) years below, starting with the current address in U.S.

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this current address From

Add another address for spouse?

YesNo

Residential Addresses - 2

Street Name and Number

Apartment Number

City

State/Province

Zip/Pin Code

Country

Dates at this address

From

Add another address for spouse?

YesNo

Residential Addresses - 3

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

Add another address for spouse?

YesNo

Residential Addresses - 4

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

Add another address for spouse?

YesNo

Residential Addresses - 5

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

Add another address for spouse?

YesNo

Residential Addresses

Click "Add Another" to add additional addresses.

Street Name and Number

Apartment Number

City

State

Zip Code

Country

Dates at this address

From

Spouse's Non-U.S. Addresses

List your permanent Non-U.S. Address

Street Name and Number (of Current Non-U.S. Residence)

Apartment No.

City

State/Province

Zip/Pin Code

Country

Dates at this address

From

______________________________________________________________________________________

Is the last non-U.S. Address where your spouse resided for more than 1 year the same as above?

YesNo

Street Name and Number (of last Non-U.S. Residence for more than 1 year)

Apartment No.

City

State/Province

Zip/Pin Code

Country

Dates at this address

From

My child(ren)'s residential history is the same as:

MineMy spouse'sOther

Spouse's Parents' Information

Father's Last Name

Father's First Name

Father's Date of Birth

please enter in (mm/dd/yyyy) format. If unknown, please enter "unknown"

Father's City of Birth

If unknown, state "unknown"

Father's Country of Birth

If unknown, state "unknown"

Father's City of Residence

If deceased, please enter "Deceased"

Father's Country of Residence

If deceased, please enter "Deceased"

Mother's Maiden Name

Last Name before marriage. Note: If your mother's full name changed after marriage, record her full maiden (before marriage) name in this field.

Mother's First Name

If your mother's FIRST name changed after marriage, record her first name before marriage in this field.

Mother's Date of Birth

please enter in (mm/dd/yyyy) format. If unknown, please enter "unknown"

Mother's City of Birth

If unknown, state "unknown"

Mother's Country of Birth

If unknown, state "unknown"

Mother's City of Residence

If deceased, please enter "Deceased"

Mother's Country of Residence

If deceased, please enter "Deceased"

Has your spouse ever filed Form I-485?

Yes

Spouse's U.S. Immigration Information

Current Status

Date of Last Arrival

City or Town of Last Entry

Record the CITY and STATE where you were inspected by U.S. Immigration, not your final U.S. destination

State of Last Entry

I-94 Number

11 digits (include leading zero, if applicable)

Date I-94 Expires

If you have received an I-797 approval notice since your last U.S. entry, use the I-94 expiration date at the bottom of your I-797.

In what status did your spouse last enter the U.S.?

Date Visa Issued

Consulate of Visa Issuance

Nonimmigrant Visa Number

The visa number (usually 8 characters) can be found on your visa in red, located towards the bottom right side of the visa. Please DO NOT put the "Control Number" in this field.

Alien Number (if any)

9 Digits (no dashes or spaces)

Spouse's U.S. Social Security Number (if any)

9 Digits (no dashes or spaces)

Passport Number

Expiration Date

Country of Issuance

I.e., the country named on the cover of the passport.

Spouse's Employment History

List your spouse's employment for the last five (5) years below, starting with the most recent job. Record your spouse's last job outside the U.S. even if it was more than five years ago.

If your spouse has been unemployed for any period within the last five years, write "None" in the Employer field and "Unemployed" in the Occupation/Job Title field.

Employer Name

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Province

Zip/Postal Code

Country

From

Add Another Employment History?

YesNo

Spouse's Employment History

Employer Name

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Province

Zip/Postal Code

Country

From

Add Another Employment History?

YesNo

Spouse's Employment History

Employer Name

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Province

Zip/Postal Code

Country

From (Year)

To (Year)

Add Another Employment History?

YesNo

Spouse's Employment History

Employer Name

Occupation/Job Title

Street Number and Name

Apt/Ste/Flr

Apt/Ste/Flr Number

City

State/Province

Zip/Postal Code

Country

From

Spouse's Employment Authorization

Has your spouse ever applied for Employment Authorization (EAD) before?

Yes

Answer the following questions about the most recent Employment Authorization Document (EAD) your spouse received, even if it has expired. Do not enter information about a pending EAD application here.

Which Service Center

Validity Date(s)

Result

Has your spouse ever applied for an Immigrant Visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad?

Yes

General Eligibility and Inadmissibility Grounds

City

Country

Decision

Date of Decision

Page 7

Spouse's Previous Spouse's (1) Biographic Data

Last Name

For wife, give maiden name

Given Name(s)

Gender

MaleFemale

Date of Birth

mm/dd/yyyy

City of Marriage

State of Marriage

Country of Marriage

Date of Marriage

mm/dd/yyyy

City of Termination of Marriage

State of Termination of Marriage

Country of Termination of Marriage

Date of Termination of Marriage

mm/dd/yyyy

Add another?

YesNo

Previous Spouse's (2) Biographic Data

Last Name

For wife, give maiden name

Given Name(s)

Gender

MaleFemale

Date of Birth

mm/dd/yyyy

City of Marriage

State of Marriage

Country of Marriage

City of Termination of Marriage

Date of Marriage

mm/dd/yyyy

State of Termination of Marriage

Country of Termination of Marriage

Date of Termination of Marriage

mm/dd/yyyy

Page 8

Child Biographic Information

Child's Last Name (as in passport)

Child's Given Name(s) (as in passport)

Child's Date of Birth

Child's City/Town of Birth

Child's State or Province of Birth

Child's Country of Birth

Child's Country of Citizenship

Gender

Child's Marital Status

Relationship

Child's Social Security Number

If none, state "None"

Child's Alien Number

If none, state "None")

Child Applying for I-485?

Yes

Child's U.S. Immigration Information

Child's Current nonimmigrant Status

Child 's Date of Last U.S. Entry

City or Town of Last Entry

Record the CITY where you were inspected by U.S. Immigration, not your final U.S. destination

State of Last Entry

Child's I-94 Number

11 digits (include leading zero, if applicable)

Date Child's Status Expires

In what status did the child last enter the U.S.?

Consulate of Visa Issuance

Date Visa Issued

Nonimmigrant Visa Number

The visa number (usually 8 characters) can be found on your visa in red, located towards the bottom right side of the visa. Please DO NOT put the "Control Number" in this field.

Child's Passport Number

Child's Passport Expiration Date

Child's Passport Country of Issuance

I.e., the country named on the cover of the passport.

Ethnicity

Race

Eye Color

Hair Color

Height (feet)

Height (inches)

Weight (in lbs)

Has your child ever applied for an Immigrant Visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad?

Yes

Location of U.S. Embassy or U.S. Consulate

City

Country

Decision

Date of Decision

Add another child?

YesNo

Second Child's Biographic Information

Second Child's Last Name (as in passport)

Second Child's Given Name(s) (as in passport)

Second Child's Date of Birth

Second Child's City/Town of Birth

Second Child's State or Province of Birth

Second Child's Country of Birth

Second Child's Country of Citizenship

Second Child Gender

Second Child's Marital Status

Relationship

Second Child's Social Security Number

If none, state "None"

Second Child's Alien Number

If none, state "None"

Second Child Applying for I-485?

Yes

Second Child's U.S. Immigration Information

Second Child's Current nonimmigrant Status

Second Child 's Date of Last Arrival

Second Child City or Town of Last Entry

Record the CITY where you were inspected by U.S. Immigration, not your final U.S. destination

State of Last Entry

Second Child's I-94 Number

11 digits (include leading zero, if applicable)

Second Child's Status Expiration Date

In what status did the second child last enter the U.S.?

Visa Issuance Date for Second Child

Consulate of Visa Issuance

Second Child Nonimmigrant Visa Number

The visa number (usually 8 characters) can be found on your visa in red, located towards the bottom right side of the visa. Please DO NOT put the "Control Number" in this field.

Second Child's Passport Number

Second Child's Passport Country of Issuance

I.e., the country named on the cover of the passport.

Second Child's Passport Expiration Date

Ethnicity

Race

Eye Color

Hair Color

Height (feet)

Height (inches)

Weight (in lbs)

Has your child ever applied for an Immigrant Visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad?

Yes

Location of U.S. Embassy or U.S. Consulate

City

Country

Decision

Date of Decision

Add another child?

YesNo

Third Child's Biographic Information

Third Child's Last Name (as in passport)

Third Child's Given Name(s) (as in passport)

Third Child's Date of Birth

Third Child's City/Town of Birth

Third Child's State or Province of Birth

Third Child's Country of Birth

Third Child's Country of Citizenship

Third Child Gender

Third Child's Marital Status

Relationship

Third Child's Social Security Number

If none, state "None"

Third Child's Alien Number

If none, state "None"

Third Child Applying for I-485?

Yes

Third Child's U.S. Immigration Information

Third Child's Current nonimmigrant Status

Third Child 's Date of Last Arrival

Third Child's City or Town of Last Entry

Record the CITY where you were inspected by U.S. Immigration, not your final U.S. destination

State of Last Entry

Third Child's I-94 Number

11 digits (include leading zero, if applicable)

Third Child's Status Expiration Date

In what status did the Third child last enter the U.S.?

Visa Issuance Date for Third Child

Consulate of Visa Issuance

Third Child Nonimmigrant Visa Number

The visa number (usually 8 characters) can be found on your visa in red, located towards the bottom right side of the visa. Please DO NOT put the "Control Number" in this field.

Third Child's Passport Number

Third Child's Passport Expiration Date

Third Child's Passport Country of Issuance

I.e., the country named on the cover of the passport.

Ethnicity

Race

Eye Color

Hair Color

Height (feet)

Height (inches)

Weight (in lbs)

Has your child ever applied for an Immigrant Visa to obtain permanent resident status at a U.S. Embassy or U.S. Consulate abroad?

Yes

Location of U.S. Embassy or U.S. Consulate

City

Country

Decision

Date of Decision

Page 9

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