OMB No. 1615-0090; Expires 03/31/2017 Department of Homeland Security U.S. Citizenship and Immigration Services Form I-687, Application for Status as a Temporary Resident Under Section 245A of the INA Do not write in this block. For USCIS Use Only. Action Block Fee Stamp Waiver of Inadmissibility Under Section 212(a)___________________ Approved Denied Class of Admission Place of Admission Applicant's A-Number Date of Adjustment START HERE - Type or print in capital letters in black ink. (If you need more space, use a separate sheet of paper.) 1. I hereby apply for status as indicated by the block checked below: A. Temporary Resident Status as an alien who illegally entered the U.S. prior to January 1, 1982. B. Temporary Resident Status as an alien who entered the U.S. as a nonimmigrant prior to January 1, 1982, and whose authorized stay expired before such date or whose unlawful status was known to the Government as of January 1, 1982. 2. Name Family Name (Last Name) Given Name (First Name) Middle Name 3. Date of Birth (mm/dd/yyyy) 4. Other A-Nos. and Names Used or Known By (including maiden name, if married) 5. Telephone Numbers (including area codes) Home Work 6. Home Address in the U.S. In Care Of Number and Street City In Care Of No. and Street Name City 8. Country of Citizenship 9. Place of Birth City or Town 10. Marital Status Now Married 11. Gender Male Female Never Married 12. Race Asian or Pacific Islander Hispanic Black, not of Hispanic origin White, not of Hispanic origin Other (specify below) Separated Divorced Widowed Country, Province, or State Country State Zip Code Apt. No. State Zip Code Apt. No. U.S. Social Security No 7. Mailing Address in the U.S. (if different from address in Number 6) Form I-687 (03/30/15) Y American LegalNet, Inc. www.FormsWorkFlow.com 13. Have you previously applied for temporary residence as a Legalization applicant? No Yes If Yes, give date, place of filing, and final disposition, if known. 14. Do you have other records with USCIS (or the former INS)? No Yes If Yes, give file numbers. A-No. 15. When did you first come to the U.S.? (mm/dd/yyyy) 17. Place of first entry into U.S. to reside: Other 16. Manner of Entry Without a visa With a visa (visitor, student, etc.) specify: Port of Entry (City and State): Border - Not through a Port of Entry (State): 18. Mother's Name Immigration Status 19. Father's Name Immigration Status Family Name Country of Birth Family Name Country of Birth Family Name Country of Birth Family Name Country of Birth Family Name Country of Birth Family Name Country of Birth Given Name Relationship Form I-687 (03/30/15) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Living A No. (Maiden Name, Last Name, First Name) Deceased (year) Living A No. (Last Name, First Name) Deceased (year) Given Name Relationship Given Name Relationship Given Name Relationship Given Name Relationship Given Name Relationship A-Number A-Number A-Number A-Number A-Number A-Number 20. List your present and past husbands/wives and all of your sons and daughters (if additional space is needed, use separate paper). If you were admitted as a nonimmigrant prior to January 1, 1982, complete Numbers 21 through 29. If not, leave blank and go to Number 30. 21. Passport Number 24. Type of Visa Issued (B-2, F-1, etc.) 22. Country that Issued Passport 25. Date Visa Issued (mm/dd/yyyy) 23. Location Where Visa Issued (City and Country) 27. Class of Admission (Student, Visitor, etc.) 26. Authorized Stay in U.S. Expired (mm/dd/yyyy) 29. Was your status violation known to the 28. Did you violate your legal Government prior to January 1, 1982? status prior to January 1, 1982? No Yes No Yes If Yes, how was your status violation known to the Government? 30. RESIDENCES IN THE UNITED STATES: List all of your residences in the United States since your first entry, beginning with your present address. If you need more space to complete, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information refers to Number 30. Number and Street Name Apt. No. City Number and Street Name City Number and Street Name City Number and Street Name City Number and Street Name City Number and Street Name City Number and Street Name City State Zip Code From (mm/yyyy) State Zip Code From (mm/yyyy) State Zip Code From (mm/yyyy) State Zip Code From (mm/yyyy) State Zip Code From (mm/yyyy) State Zip Code From (mm/yyyy) State Zip Code From (mm/yyyy) To (mm/yyyy) Apt. No. To (mm/yyyy) Apt. No. To (mm/yyyy) Apt. No. To (mm/yyyy) Apt. No. To (mm/yyyy) Apt. No. To (mm/yyyy) Apt. No. To (mm/yyyy) Form I-687 (03/30/15) Y Page 3 American LegalNet, Inc. www.FormsWorkFlow.com 31. AFFILIATIONS OR ASSOCIATIONS: List all affiliations or associations, clubs, organizations, churches, unions, businesses, etc. to which you belong or have belonged. If you need more space to complete, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information refers to Number 31. Name of Organization Location (City and State) From (mm/yyyy) To (mm/yyyy) 32. ABSENCES FROM THE UNITED STATES SINCE FIRST ENTRY: List most recent absence first and then all previous absences dating back to your first entry. If you need more space to complete, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information refers to Number 32. From (mm/yyyy) To (mm/yyyy) Purpose of Trip Country Manner of Reentry (type of visa, EWI) Form I-687 (03/30/15) Y Page 4 American LegalNet, Inc. www.FormsWorkFlow.com 33. EMPLOYMENT IN THE UNITED STATES SINCE FIRST ENTRY: Show most recent employment first and then all previous employment dating back to your first entry. If none, write "None." If you need more space to complete, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information refers to Number 33. Full Name of Employer Number and Street Name City Annual Wage Full Name of Employer Number and Street Name City Annual Wage Full Name of Employer Number and Street Name City Annual Wage Full Name of Employer Number and Street Name City Annual Wage Full Name of Employer Number and Street Na