Application to Replace Permanent Resident Card Department of Homeland Security U.S. Citizenship and Immigration Services Applicant Interviewed Date: Class of Admission For USCIS Use Only Remarks Receipt USCIS Form I-90 OMB No. 1615-0082 Expires 07/31/2019 Action Block START HERE - Type or print in black ink. Part 1. Information About You 1. Alien Registration Number (A-Number) Mailing Address 6.a. In Care Of Name A2. USCIS Online Account Number (if any) 6.b. Street Number and Name 6.c. Apt. Ste. Flr. Your Full Name NOTE: Your card will be issued in this name. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 6.d. City or Town 6.e. State 6.g. Province 6.h. Postal Code 6.i. Country 6.f. ZIP Code 4. Has your name legally changed since the issuance of your Permanent Resident Card? Yes (Proceed to Item Numbers 5.a. - 5.c.) No (Proceed to Item Numbers 6.a. - 6.i.) N/A - I never received my previous card. (Proceed to Item Numbers 6.a. - 6.i.) Physical Address Provide this information only if different than mailing address. 7.a. Street Number and Name 7.b. Apt. Ste. Flr. Provide your name exactly as it is printed on your current Permanent Resident Card. NOTE: Attach all evidence of your legal name change with this application. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 7.c. City or Town 7.d. State 7.f. Province 7.e. ZIP Code 7.g. Postal Code 7.h. Country Form I-90 02/27/17 N Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Part 1. Information About You (continued) Additional Information 8. 9. 10. Gender Date of Birth Male Female Reason for Application (Select only one box) Section A. (To be used only by a lawful permanent resident or a permanent resident in commuter status.) 2.a. 2.b. 2.c. 2.d. My previous card has been lost, stolen, or destroyed. My previous card was issued but never received. My existing card has been mutilated. My existing card has incorrect data because of Department of Homeland Security (DHS) error. (Attach your existing card with incorrect data along with this application.) My name or other biographic information has been legally changed since issuance of my existing card. My existing card has already expired or will expire within six months. I have reached my 14th birthday and am registering as required. My existing card will expire AFTER my 16th birthday. (See NOTE below for additional information.) I have reached my 14th birthday and am registering as required. My existing card will expire BEFORE my 16th birthday. (See NOTE below for additional information.) NOTE: If you are filing this application before your 14th birthday, or more than 30 days after your 14th birthday, you must select reason 2.j. However, if your card has expired, you must select reason 2.f. 2.h.1. 2.h.1.a. I am a permanent resident who is taking up commuter status. My Port-of-Entry (POE) into the United States will be: City or Town and State (mm/dd/yyyy) City/Town/Village of Birth 11. Country of Birth Mother's Name 12. Given Name (First Name) 2.e. 2.f. 2.g.1. Father's Name 13. Given Name (First Name) Class of Admission 14. 2.g.2. 15. Date of Admission (mm/dd/yyyy) 16. U.S. Social Security Number (if any) Part 2. Application Type NOTE: If your conditional permanent resident status (for example: CR1, CR2, CF1, CF2) is expiring within the next 90 days, then do not file this application. (See the What is the Purpose of This Application section of the Form I-90 Instructions for further information.) My status is (Select only one box): 1.a. 1.b. 1.c. Lawful Permanent Resident (Proceed to Section. A.) Permanent Resident - In Commuter Status (Proceed to Section. A.) Conditional Permanent Resident (Proceed to Section B.) 2.h.2. 2.i. 2.j. I am a commuter who is taking up actual residence in the United States. I have been automatically converted to lawful permanent resident status. I have a prior edition of the Alien Registration Card, or I am applying to replace my current Permanent Resident Card for a reason that is not specified above. Form I-90 02/27/17 N Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Application Type (continued) Section B. (To be used only by a conditional permanent resident.) 3.a. 3.b. 3.c. 3.d. My previous card has been lost, stolen, or destroyed. My previous card was issued but never received. My existing card has been mutilated. My existing card has incorrect data because of DHS error. (Attach your existing permanent resident card with incorrect data along with this application.) My name or other biographic information has legally changed since the issuance of my existing card. Biographic Information 6. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 7. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 8. Height Weight Eye Color (Select only one box) Black Blue Green Pink Brown Hazel Unknown/Other Gray Maroon 11. Feet Inches Pounds 3.e. Part 3. Processing Information 1. Location where you applied for an immigrant visa or adjustment of status: 9. 10. 2. Location where your immigrant visa was issued or USCIS office where you were granted adjustment of status: Hair Color (Select only one box) Bald (No hair) Brown Sandy Black Gray White Blond Red Unknown/Other Complete Item Numbers 3.a. and 3.a1. if you entered the United States with an immigrant visa. (If you were granted adjustment of status, proceed to Item Number 4.) 3.a. Destination in the United States at time of admission 3.a.1. Port-of-Entry where admitted to the United States: City or Town and State Part 4. Accommodations for Individuals with Disabilities and/or Impairments (Read the information in the Form I-90 Instructions before completing this part.) NOTE: If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 1. Are you requesting an accommodation because of your disabilities and/or impairments? Yes No 4. Have you ever been in exclusion, deportation, or removal proceedings or ordered removed from the United States? Yes No 5. Since you were granted permanent residence, have you ever filed Form I-407, Abandonment by Alien of Status as Lawful Permanent Resident, or otherwise been determined to have abandoned your status? Yes No If you answered "Yes," select any applicable boxes: 1.a. I am deaf or hard of hearing and request the following accommodation (If you