Application to Adjust Status From Temporary to Permanent Resident (Under Section 245A of the INA) Department of Homeland Security U.S. Citizenship and Immigration Services Receipt USCIS Form I-698 OMB No. 1615-0035 Expires 03/31/2019 Applicant Interviewed Date: For USCIS Date of Adjustment Use Only Remarks Date: START HERE - Type or print in black ink. Action Block Part 1. Information About You 1. Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name 2. Name as it Appears on Your Employment Authorization Document (Form I-766) A. Family Name (Last Name) Given Name (First Name) Middle Name B. Provide the reason for a difference in the names, if any (marriage, divorce, etc.) 3. Any Other Names Used A. Family Name (Last Name) Given Name (First Name) Middle Name B. Family Name (Last Name) Given Name (First Name) Middle Name 4. A. If your native alphabet does not use Roman letters, type or print your name in your native alphabet. Family Name (Last Name) Given Name (First Name) Middle Name B. Language of Your Native Alphabet 5. U.S. Mailing Address In Care Of Name Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 6. Is your current U.S. mailing address the same as your U.S. physical address? If you answered "No," provide your U.S. physical address in Item Number 7. Yes No Form I-698 03/03/17 Y Page 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Part 1. Information About You (continued) 7. U.S. Physical Address Street Number and Name A- Apt. Ste. Flr. Number City or Town State ZIP Code 8. Alien Registration Number (A-Number) (if any) 9. U.S. Social Security Number (if any) A10. Date of Birth (mm/dd/yyyy) 11. Gender Male 12. Place of Birth City or Town Province or Foreign State Country Female 13. Country of Citizenship or Nationality 14. Mother's First Name 15. Father's First Name 16. Marital Status Single (Never Married) Married Divorced or Separated Widowed 17. List absences from the United States since becoming a temporary resident. List the most recent absence first. If you have a single absence that exceeded 30 days or if the total of all of your absences exceeds 90 days, explain using the space provided in Part 8. Additional Information or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of the sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. Country Purpose of Trip From (mm/dd/yyyy) To (mm/dd/yyyy) Total Days Absent Part 2. Biographic Information 1. 2. Ethnicity (Select only one box) Race (Select all applicable boxes) White 3. 5. Height Feet Asian Black or African American Inches 4. Weight American Indian or Alaska Native Pounds Native Hawaiian or Other Pacific Islander Hispanic or Latino Not Hispanic or Latino Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6. Hair Color (Select only one box) Bald (No Hair) Black Blond Brown Gray Red Sandy White Unknown/ Other Form I-698 03/03/17 Y Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Eligibility Standards 1. A- You are required to have a minimal understanding of standard English and a knowledge and understanding of the history and Government of the United States. Select the appropriate box in Item A. or B. below. A. I will satisfy these requirements through: An examination at the time of interview for lawful permanent residence; or Satisfactory pursuit of a course of study recognized by the Secretary of Homeland Security (Secretary). B. I have satisfied these requirements by: Satisfactory pursuit of a course of study recognized by the Secretary (attach appropriate documentation); or An exemption because I am 65 years of age or older, under 16 years of age, or I am physically unable to comply. (If you are physically unable to comply, explain and attach relevant documentation.) Answer Item Numbers 2. - 29. If you answer "Yes" to any of the questions, provide a complete explanation using the space provided in Part 8. Additional Information or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. Answering "Yes" does not necessarily mean that you are not entitled to adjust status or register for lawful permanent residence. 2. 3. 4. 5. Have you EVER assisted in the persecution of any person or persons on account of race, religion, political opinion, nationality, or membership in a particular social group? Have you EVER been treated for a mental disorder, drug addiction, or alcoholism? Have you EVER committed a crime or offense for which you were not arrested? Have you EVER been arrested, cited, or detained by any law enforcement officer (including Immigration and Customs Enforcement (ICE), Customs and Border Protection (CBP), former Immigration and Naturalization Service (INS), and/or military officers) for any reason? Have you EVER been charged with committing any crime or offense? Have you EVER been convicted of a crime or offense? Have you EVER been in jail or prison? Have you EVER been placed in an alternative sentencing or a rehabilitative program (for example, diversion, deferred prosecution, withheld adjudication, deferred adjudication)? Yes Yes Yes Yes No No No No 6. 7. 8. 9. Yes Yes Yes Yes Yes Yes No No No No No No 10. Have you EVER received a suspended sentence, been placed on probation, or been paroled? 11. A. Have you, or a dependent member of your immediate family, EVER received public assistance from any source, including, but not limited to, the U.S. Government, any state, county, city, or municipality? B. If "Yes," provide the names of the recipients and their U.S. Social Security Numbers below. Full Name of Recipient (Family Name, Given Name, Middle Name) U.S. Social Security Number 12. Have you EVER: A. Within the past 10 years been a prostitute, procured anyone for prostitution, or intend to engage in such activities in the future? B. Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling? C. Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally? D. Illicitly trafficked in any controlled substance or knowingly assisted, abetted, or colluded in the illicit trafficking of any controlled substance? Form I-698 03/03/17 Y Yes Yes Yes Yes No