OMB No: 1615-0070; Expires 10/31/2012 Department of Homeland Security U.S. Citizenship and Immigration Services What Is the Purpose of This Form? Refugees and asylees, Cuban/Haitian Entrants under the Act of November 1, 1996, and Amerasians under Public Law 97-359 should submit Form I-643 when filing an application for adjustment of status. This form should be fully completed by a refugee or asylee who is 16 years of age or older. Representatives of applicants younger than 16 years of age should only complete Blocks 1 and 2. Although the information requested on Form I-643 will not affect the adjudication of the adjustment application, your application will not be considered as completely filed unless you submit this form. The data collected on this form will be used by U.S. Department of Health and Human Services to compile and analyze statistics relating to refugees and asylees. Form I-643 will not be retained by U.S. Citizenship and Immigration Services (USCIS). How to Complete Form I-643 NOTE: Applicant - Print or type in blue or black ink Section 1 Enter your name, the date on which you are completing this form, and your Alien Registration Number on the first line. On the second line, enter your country of birth and your country of citizenship. On the third line, enter your native language, your date of birth, and your telephone number. Enter your current address on the fourth line. Section 2 Fill in your three most recent cities and states of residence in the United States in order, starting with your current place of residence. If you have not lived in three different cities since you entered the United States, write "None" on as many lines as appropriate. Section 3 Show the total number of people living in your household and the number currently employed. Fill in the first line for yourself, then list any other persons who live in your household. If more than five persons live with you, attach a separate page listing the others and provide the information requested. I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status At the bottom of the block enter your major occupation before coming to the United States. If you did not work before coming to the United States, enter "None." Section 5 Check the block or blocks that best describe your education before coming to the United States. Also, check the block or blocks that best describe how and where you have learned English. Section 6 If you have had any training or education in the United States, check the block or blocks that best describe your training and enter your major course of study. If you have not had any training in the United States, enter "None." Section 7 Check the appropriate block that best describes your ability to speak, read, and write English. Section 8 Check as many types of public assistance that you have received or someone has received on your behalf. Indicate the month and year the assistance started and stopped. If you are still receiving assistance, write "Present" in the block headed "To (mm/yyyy)," noting month/year. Paperwork Reduction Act An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 55 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Products Division, Office of the Executive Secretariat, 20 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0070. Do not mail your application to this address. Section 4 Enter the information about all jobs you have held since coming to the United States, starting with your current or most recent job. Under "Job Title" write the term that best describes the work you do, such as "machine operator," "nurse," or "chemist." If you have not worked at all since coming to the United States, write "None." Form I-643 Instructions (Rev. 10/08/10) Y American LegalNet, Inc. www.FormsWorkFlow.com Privacy Act Notice USCIS asks for the information on this form, and associated evidence, to determine if you have established eligibility for the immigration benefit for which you are filing. Our legal right to ask for this information is in 8 U.S.C. 1302 and 1304. USCIS may provide this information to other government agencies. Failure to provide this information, and any requested evidence, may delay a final decision or result in denial of your request. Instructions to USCIS Officer After this form has been completed, forward it directly to the address as shown below (If you are mailing a small number of forms, they may be folded so that the address shows through a #10 window envelope). Data Unit, Office of Refugee Resettlement Department of Health and Human Services 370 L'Enfant Promenade S.W., (6th Floor) Washington, DC 20447 Form I-643 Instructions (Rev. 10/08/10) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com OMB No: 1615-0070; Expires 10/31/2012 I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status Department of Homeland Security U.S. Citizenship and Immigration Services Print or type in blue or black ink. Last (Family) First (Given) 1. Name: Country of Birth: Middle Today's Date: (mm/dd/yyyy) Country of Citizenship/Nationality: Native Language: Date of Birth (mm/dd/yyyy) Telephone Number (with area code) Alien Registration Number: ASocial Security Number: Cellphone Number (with area code) Current Address: (Number, Street, and Apartment No.) (State) (City) 2. My three most recent cities of residence in the United States have been: City or Town 3. There are Name From (mm/dd/yyyy) State of whom are employed. members of the household, Relationship Gender Date of Birth Country of Alien Number (mm/dd/yyyy) to Me M/F Birth (Self) (Zip Code) (List most recent first) To (mm/dd/yyyy) Present (Please use another sheet(s) if needed) Currently Employed? Attending School? Yes No Yes No (Self) 4. My employment since entering the United States has been: (List most recent first) Location To From Company Name City, State (mm/dd/yyyy) (mm/dd/yyyy) Check One Wage Per Part Full Hour Time Time Job Title My major occupation or profession before coming to the United States was: 5. My education before coming to the United States was: Grades 1-8 Some high school High school diploma Technical school Technical school certificate Some university University diploma Graduate studies Professional training Graduate degree 6. I have had the following training or education in the U.S. Type of Training/Education (Check all that apply) My knowledge of English was acquired by: (Check all that apply) Use in another country Training in the U.S. Use in the U.S. Training in refugee camp Training in another country Other (Please explain): (Check all that apply) 7. English Language Skills: (Check one) Check If Still Attending High School College Technical/Vocational Check If Completed Speaking None Good A Few Words Fair Reading Course of Study None Good None A Few Words Fair Writing A Few Words Fair Other (specify): Good 8. Since in the United States, list as many types of public assistance (excluding emergency medical treatment) that you have received or someone has received on your behalf. Please include public assistance received from the U.S. Government or any State, county, city, or municipality. Public Assistance From (mm/yyyy) To (mm/yyyy) Public Assistance Cash assistance (Welfare) To (mm/yyyy) Medical assistance Food Stamps From (mm/yyyy) Other (specify): SSI Form I-643 (Rev. 10/08/10) Y American LegalNet, Inc. www.FormsWorkFlow.com