Form I-485 12/13/17 N Page 1 of 18 1.b. 1.c. 1.a.Family Name (Last Name) Given Name (First Name) Middle Name Your Current Legal Name (do not provide a nickname)Application to Register Permanent Residence or Adjust Status Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-485 OMB No. 1615-0023Expires 06/30/2019 Priority Date: Country Chargeable:INA 209(a) INA 249 Section of LawINA 245(a)INA 245(i)INA 245(m)Sec. 13, Act of 9/11/57Cuban Adjustment ActOther Lawful Permanent Resident as of: Date of Initial Interview: Action Block Receipt Interview WaivedApplicant Interviewed Date Form I-693 Received: Attorney State Bar Number (if applicable) Select this box if Form G-28 is attached.Volag Number (if any) Attorney or Accredited Representative USCIS Online Account Number (if any) To be completed by an attorney or accredited representative (if any). For USCIS Use Only START HERE - Type or print in black ink.NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, U.S. Citizenship and Immigration Services (USCIS) may deny your application. Part 1. Information About You (Person applying for lawful permanent residence) A- A-NumberNOTE: Provide all other names you have ever used, including your family name at birth, other legal names, nicknames, aliases, and assumed names. If you need extra space to complete this section, use the space provided in Part 14. Additional Information. Other Names You Have Used Since Birth (if applicable) 2.b. 2.c. 2.a.Family Name (Last Name) Given Name (First Name) Middle Name 3.b. 3.c. 3.a.Family Name (Last Name) Given Name (First Name) Middle Name 5.Date of Birth (mm/dd/yyyy) NOTE: In addition to providing your actual date of birth, include any other dates of birth you have used in connection with any legal names or non-legal names in the space provided in Part 14. Additional Information. Female MaleSex6.INA 209(b) 4.b. 4.c. 4.a.Family Name (Last Name) Given Name (First Name) Middle Name Preference Category: Other Information About YouCity or Town of Birth7. American LegalNet, Inc. www.FormsWorkFlow.com Form I-485 12/13/17 N Page 2 of 18 A- A-NumberCountry of Birth8. Country of Citizenship or Nationality9. Part 1. Information About You (Person applying for lawful permanent residence) (continued) A-Alien Registration Number (A-Number) (if any)10.NOTE: If you have EVER used other A-Numbers, include the additional A-Numbers in the space provided in Part 14. Additional Information. 11.USCIS Online Account Number (if any) U.S. Mailing Address City or Town13.d.ZIP Code13.f.State13.e.Street Number and Name13.b. 13.c.Apt. Flr. Ste. 13.a. In Care Of Name (if any) Passport Number Used at Last Arrival15. Travel Document Number Used at Last Arrival16. Recent Immigration History17.Expiration Date of this Passport or Travel Document (mm/dd/yyyy) Country that Issued this Passport or Travel Document18. Nonimmigrant Visa Number from this Passport (if any)19.20.a.Place of Last Arrival into the United States City or Town20.b. StateDate of Last Arrival (mm/dd/yyyy) 21.Provide the information for Item Numbers 15. - 19. if you last entered the United States using a passport or travel document. City or Town14.d.ZIP Code14.f.State14.e.Street Number and Name14.b. 14.c.Apt. Flr. Ste. 14.a. In Care Of Name (if any) Alternate and/or Safe Mailing Address If you are applying based on the Violence Against Women Act (VAWA) or as a special immigrant juvenile, human trafficking victim (T nonimmigrant), or victim of a qualifying crime (U nonimmigrant) and you do not want USCIS to send notices about this application to your home, you may provide an alternative and/or safe mailing address.When I last arrived in the United States, I:Was inspected at a port of entry and admitted as (for example, exchange visitor; visitor, waived through; temporary worker; student): 22.a. U.S. Social Security Number (if any) 12.Was inspected at a port of entry and paroled as (for example, humanitarian parole, Cuban parole): 22.b.Came into the United States without admission or parole. 22.c.Other: 22.d.If you were issued a Form I-94 Arrival-Departure Record Number:Expiration Date of Authorized Stay Shown on Form I-94 23.b.(mm/dd/yyyy) 23.c.Status on Form I-94 (for example, class of admission, or paroled, if paroled) Form I-94 Arrival-Departure Record Number 23.a. (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Form I-485 12/13/17 N Page 3 of 18 A- A-Number Part 1. Information About You (Person applying for lawful permanent residence) (continued)Provide your name exactly as it appears on your Form I-94 (if any) 25.b. 25.c. 25.a.Family Name (Last Name) Given Name (First Name) Middle Name Part 2. Application Type or Filing CategoryNOTE: Attach a copy of the Form I-797 receipt or approval notice for the underlying petition or application, as appropriate.I am applying to register lawful permanent residence or adjust status to that of a lawful permanent resident based on the following immigrant category (select only one box). (See the Form I-485 Instructions for more information, including any Additional Instructions that relate to the immigrant category you select.):1.a.Family-basedImmediate relative of a U.S. citizen, Form I-130 Other relative of a U.S. citizen or relative of a lawful permanent resident under the family-based preference categories, Form I-130 Person admitted to the United States as a fianc351(e) or child of a fianc351(e) of a U.S. citizen, Form I-129F (K-1/K-2 Nonimmigrant) Widow or widower of a U.S. citizen, Form I-360 VAWA self-petitioner, Form I-360 Alien worker, Form I-140 Alien entrepreneur, Form I-526 Employment-based 1.b.Special Immigrant Special immigrant juvenile, Form I-360Certain Afghan or Iraqi national, Form I-360 Religious worker, Form I-360Certain international broadcaster, Form I-360 Certain G-4 international organization or family member or NATO-6 employee or family member, Form I-360 1.c.Asylee or Refugee Asylum status (INA section 208), Form I-589 or Form I-730 Refugee status (INA section 207), Form I-590 or Form I-730 1.d.Human Trafficking Victim or Crime Victim Crime victim (U Nonimmigrant), Form I-918, derivative family member, Form I-918A, or qualifying family member, Form I-929 Human trafficking victim (T Nonimmigrant), Form I-914 or derivative family member, Form I-914A1.e. Dependent status under the Haitian Refugee Immigrant Fairness Act for battered spouses and children Diplomats or high ranking officials unable to return home (Section 13 of the Act of September 11, 1957) Lautenberg Parolees Dependent status under the Haitian Refugee Immigrant Fairness ActIndochinese Parole Adjustment Act of 2000 The Cuban Adjustment Act for battered spouses and children The Cuban Adjustment Act Special Programs Based on Certain Public Laws1.f.Additional Options Diversity Visa program Individual born in the United States under diplomatic status Continuous residence in the United States since before January 1, 1972 ("Registry") Other eligibility1.g. Are you applying for adjustment based on the Immigration and Nationality Act (INA) section 245(i)? Yes No2.NOTE: If you answered "Yes" to Item Number 2., you must have selected a family-based, employment-based, special immigrant, or Diversity Visa immigrant category listed above in Item Numbers 1.a. - 1.g. as the basis for your application for adjustment of status. Fill out the rest of this application and Supplement A to Form I-485, Adjustment of Status Under Section 245(i) (Supplement A). For detailed filing instructions, read the Form I-485 Instructions (including any Additional Instructions that relate to the immigrant category that you selected in Item Numbers 1.a. - 1.g.) and Supplement A Instructions.What is your current immigration status (if it has changed since your arrival)?24. American LegalNet, Inc. www.FormsWorkFlow.com Form I-485 12/13/17 N Page 4 of 18 A- A-Number Part 2. Application Type or Filing Category (continued) Information About Your Immigrant CategoryIf you are the principal applicant, provide the following information.Receipt Number of Underlying