Application for Family Unity Benefits Department of Homeland Security U.S. Citizenship and Immigration Services For USCIS Use Only Returned Resubmitted Received Relocated Sent Remarks Initial Application Approved From To / / / Denied / / / Request for Extension Approved From To / / / Denied / / / USCIS Form I-817 OMB No. 1615-0005 Expires 10/31/2017 Fee Stamp Action Block To be completed by an attorney or BIA-accredited representative (if any). Select this box if Form G-28 is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink. NOTE: You must reside and file Form I-817 while in the United States. Part 1. Information About You (Person Requesting Family Unity Benefits) 1. Alien Registration Number (A-Number) (if any) Other Information 5. Date of Birth (mm/dd/yyyy) U.S. Social Security Number (if any) A- 6. Your Full Name 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 7. USCIS Online Account Number (if any) 8. 9. Gender Country of Birth Male Female Other Names Used Provide any other names you have used since birth, including maiden names, and nicknames. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 10. Country of Citizenship or Nationality U.S. Mailing Address 11.a. In Care of Name 11.b. Street Number and Name 11.c. Apt. Ste. Flr. 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 11.d City or Town 11.e. State 11.f. ZIP Code Form I-817 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 12 Part 1. Information About You (Person Requesting Family Unity Benefits) (continued) U.S. Physical Address 12.a. Street Number and Name 12.b. Apt. Ste. Flr. 1.c. On December 1, 1988, I was the spouse of an alien who was legalized as a Special Agricultural Worker under section 210 of the INA. On December 1, 1988, I was the unmarried child under 21 years of age of an alien who was a legalized alien as a Special Agricultural Worker under section 210 of the INA. On May 5, 1988, I was the spouse of a legalized alien who adjusted status under section 202 of the Immigration Reform and Control Act of 1986 (Cuban/Haitian Adjustment). On May 5, 1988, I was the unmarried child under 21 years of age of a person who adjusted status under section 202 of the Immigration Reform and Control Act of 1986 (Cuban/Haitian Adjustment). I am the spouse of a person who is eligible for and has filed or adjusted status under section 1104 of Public Law (P.L.) 106-5534, the Legal Immigration Family Equality (LIFE) Act. I entered the United States on or before December 1, 1988, and resided in the United States on that date. I am the unmarried child under 21 years of age of a person who had filed an adjustment of status application or adjusted status under section 1104 of P. L. 106-5534, the LIFE Act. I entered the United States on or before December 1, 1988, and resided in the United States on that date. 1.d. 1.e. 12.c. City or Town 12.d. State 12.e. ZIP Code 1.f. Biographic Information 13. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 14. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 15. 16. 17. Height Weight Eye Color (Select only one box) Black Gray Maroon 18. Blue Green Pink Brown Hazel Unknown/Other Feet Inches Pounds 1.h. 1.g. Hair Color (Select only one box) Bald (No hair) Brown Sandy Black Gray White Blond Red Unknown/Other NOTE: To be eligible for Immigration Act of 1990 (IMMACT 90) Family Unity Program benefits, your qualifying spouse or parent must have maintained his or her status as a legalized alien or as a U.S. citizen, if he or she naturalized. If deceased, he or she must have maintained status until his or her death. For LIFE Act Family Unity, your spouse or parent must be eligible for adjustment or have adjusted status under section 1104 of the LIFE Act. If you previously qualified for LIFE Act Family Unity, you may be eligible to apply for IMMACT 90 Family Unity Program Benefits. I am requesting: (Select only one box) 2.a. 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 the LIFE Act Amendments. An extension of Family Unity benefits under section 1504 of the LIFE Act Amendments. Part 2. Basis For Application I am applying for Family Unity benefits because: (Select only one box) 1.a. On May 5, 1988, I was the spouse of an alien who was legalized under section 245A of the Immigration Nationality Act (INA). On May 5, 1988, I was the unmarried child under 21 years of age of an alien who was legalized under section 245A of the INA. 2.b. 2.c. 2.d. 1.b. Form I-817 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 12 Part 3. Information About Your Relationship If you need extra space to complete Part 3., use the space provided in Part 9. Additional Information 12. Email Address (if any) Information About Your Spouse or Parent Provide the following information about the legalized alien through whom you are claiming your eligibility. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Other Names Used (Including maiden name, nicknames, etc.) 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. 5. 6. Date of Birth (mm/dd/yyyy) A-Number (if any) Complete Only if You Are Applying Based on a Marital Relationship or You Were Previously Married 13. Marital Status Married Divorced Widowed Separated Provide the following information about you and your spouse. 14.a. Number of times you have been married (including current marriage) 14.b. Number of times your spouse has been married (including spouse's current marriage) If currently married, provide the following information about your marriage. 15.a. Date of Marriage (mm/dd/yyyy) Place of Marriage 15.b. City or Town 15.c. State 15.d. Province 15.e. Country A- USCIS Online Account Number (if any) 15.f. Type of Ceremony: Religious Civil None 7. U.S. Social Security Number (if any) 15.g. We are: Living together Not living together 15.h. If you selected "Not living together," (select only one box): 8. 9. Gender Male Female My spouse has died We are separated We are divorced