ADJUSTMENT OF STATUS QUESTIONNAIRE

l. PERSONAL INFORMATION
Name:
Other Names Used:
Name on alien registration card:
Sex:	Male Female	Height:
Like to change your name:	Yes No
If yes, print your new name:
Present marital status:	Single Married (Please fill Section II) Widowed Divorced (Please fill Section III)
Address in US:
Telephone/Mobile/ Email:
Date of Birth:		City and Country of Birth:
Citizenship:
A#:
Social Security #:

ll. CURRENT SPOUSE INFORMATION
Name:
Current Address:
Telephone:
Date of Birth:		City and Country of Birth:
Date & Place of Marriage:
Citizenship:		Immigration status (if not U.S. citizen):
A# if any:
Social Security #:
Date & Please of naturalization:

lll. PREVIOUS MARRIAGE INFORMATION
I have been married time(s). (*If you or your spouse were previously married, please provide the following information for all your prior marriages.)
	Yourself	Current Spouse
Name of Prior Spouse
When & Where did the Marriage take place?
When & How did the marriage end?
Immigration Status of Prior Spouse

lV. RECENT IMMIGRATION HISTORY
Passport # used at last arrival
Expiration Date: (mm/dd/yyyy)
Country that issued this Passport?
Visa Number:
Place of last arrival in US?
I-94:
Current Immigration Status (if it has changed since arrival)?
Filing Category:	Family Based Employment Based Special Immigrant Asylee or Refugee Human Trafficking or Crime Victim Additional Options
Information about your immigrant category:	Receipt # Priority Date: Principal Applicant’s Name: A#:
Have you ever applied for an immigrant visa for PR at a U.S Embassy or US Consulate	Yes No

V. ADDITIONAL INFORMATION ABOUT YOU
Street & Number	City / State	Country	From (mm/dd/yyyy)	To (mm/dd/yyyy)

Vl. EMPLOYMENT HISTORY DURING THE LAST 5 YEARS (START WITH MOST RECENT)
Employer’s Name:	Work Address:	Your occupation:	From (mm/dd/yyyy)	To (mm/dd/yyyy)

Vlll. How many children do you have? Please complete the following information for each child.
Full Name	Male/ Female	Date of Birth	Country & City of Birth	Current City & Country of Residence

Vll. Information About Your Parents
Full name of child	Date of birth	Birth Country	Citizenship	Current Address

IX. Biographic Information
Ethnicity:	Hispanic or Latino Not Hispanic or Latino
Race	White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other
Height & Weight (lbs):
Eye & Hair Color:

X. General Eligibility and Inadmissibility Grounds
Have you ever been a member of, involved in or in any way association, fund, foundation, party, club, society, or similar group in the US or in any other location in the work many of your parents are U.S. citizens?	Yes No

Xl. Other Factors
Please tick in appropriate columns	Yes	No
1. Have you ever aided, supported, or been a member of a totalitarian or communist party?
2. Nazi affiliations?
3. Participated in the persecution of any person because of race, religion, national origin, or political opinion?
4. Deserted the Armed Forces of the U.S. or avoided being drafted?
5. Have you ever registered under Selective Service? If so, complete the following: Selective Service Number: _____________________________________ Date Registered: _____________________________________________ If not, were you required to do so? If required (males between 18 and 26 years old), why didn’t you register?
6. Have you ever applied for exemption from military service?
7. Since becoming a permanent resident, have you
a) Failed to file a federal income tax return?
b) failed to file a tax return because you considered yourself a nonresident?
c) filed a tax return as a nonresident?
8. Have you ever been deported or had deportation proceedings against you?
9. Have you ever practiced, used, or been involved in any of the following:
a) alcohol abuse/alcoholism?
b) polygamy?
c) prostitutio
d) illegal entry of foreigners?
e) drugs (narcotics)?
f) illegal gambling?
10. Have you given false testimony for immigration benefits?
11. Have you ever claimed to be a U.S. citizen?
12. Have you ever declared legally incompetent or confined as a mental patient?
13. Do you hold nobility in any foreign state? Ties or lineage?
14. Have you ever committed any crime or ever been arrested for violating any law (excluding traffic regulations)?
15. Have you ever been on probation? If so, why? When did probation end?
16. If you have children not living with you, are you under financial child support obligations? If so, what are they?
Have you always complied with those obligations?
If not, are you in compliance now?

Xll. Accommodations for Individuals with Disabilities and/or Impairments
Are you requesting an accommodation because of your Please tick in appropriate columns	Yes				No

Xlll. Documents Required
	Copy of your green card (front and back)
	Copy of your passport (old and current) with all biographic pages and all dates (Departures and Arrivals - legible from the Passport)
	Copy of current driver’s license or Government ID
	Four passport size pictures (2” X 2” color frontal view with white background)
	Copy of your SS card
	I-120s (if any)
	Copy of spouse’s citizenship certificate or green card, if available,
	Copy of marriage certificate, if available.
	Copy of Divorce certificate, if available.
	Copy of birth certificate, (English & it’s true translated version)
	Copy of EAD if issued earlier.