I-485 Intake Form

Application to Register Permanent Residence or Adjust Status

Please complete this intake form to help us prepare your I-485 application. All information is confidential.

Full Legal Name *

Other Names Used (maiden name, aliases, nicknames)

Date of Birth

Place of Birth (City, Country)

Country of Citizenship

Social Security Number (if any)

A-Number (if any)

Gender

Male

Female

Marital Status

Phone Number *

Email Address *

Current U.S. Address

Street Address

Apt/Unit #

City

State

ZIP Code

Date From

List all addresses for the past 5 years

Class of Admission (visa type when entered)

Date of Last Entry to U.S.

Place of Entry (City, State)

I-94 Number

Passport Number

Passport Country

Passport Expiration Date

Current Immigration Status

Basis for Eligibility *

Priority Date (if applicable)

Receipt Number of Approved Petition

I certify that the information provided is true and correct to the best of my knowledge. I understand that providing false information may result in denial of the application and possible legal consequences. I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.

I agree to the above certification *

Someone Detained by ICE?

I-485 Intake Form

Current U.S. Address