Petition to Remove Conditions on Residence Department of Homeland Security U.S. Citizenship and Immigration Services Receipt Action Block USCIS Form I-751 OMB No. 1615-0038 Expires 11/30/2017 Remarks For USCIS Use Only Reloc Sent Reloc Received Date (mm/dd/yyyy) Date (mm/dd/yyyy) / / / / / / Date (mm/dd/yyyy) Date (mm/dd/yyyy) / / / / / / Petitioner interviewed on (mm/dd/yyyy) / / / Approved under INA 216(c)(4)(C) Battered Spouse/Child To be completed by an attorney or accredited representative (if any). Select this box if Form G-28 is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink. Part 1. Information About You, the Conditional Resident 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 5. Country of Birth 6. Country of Citizenship or Nationality (provide all that apply) 7. Alien Registration Number (A-Number) (if any) A- Other Names Used List all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 11. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 8. U.S. Social Security Number (if any) 9. USCIS Online Account Number (if any) Marital Status 10. Marital Status Single 11. 12. Married Divorced Widowed Date of Marriage (mm/dd/yyyy) Place of Marriage 13. If the marriage through which you gained conditional residence has ended, provide the date it ended (date of divorce or date of death) (mm/dd/yyyy) Other Information 4. Date of Birth (mm/dd/yyyy) 14. Conditional Residence Expires On (mm/dd/yyyy) Form I-751 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 11 Part 1. Information About You, the Conditional Resident (continued) Mailing Address 15.a. In Care Of Name 21. If you are married, is this a different marriage than the one through which you gained conditional resident status? Yes No 22. Have you resided at any other address since you became a permanent resident? Yes No 15.b. Street Number and Name 15.c. Apt. Ste. Flr. If you answered "Yes" to Item Number 22., provide a list of all addresses where you have resided since becoming a permanent resident and the dates you resided at those locations in the space provided in Part 11. Additional Information. 23. Is your spouse or parent's spouse currently serving with or employed by the U.S. Government and serving outside the United States? Yes No 15.d. City or Town 15.e. State 16. 15.f. ZIP Code Is your physical address different than your mailing address? Yes Part 2. Biographic Information No 1. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 2. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander If you answered "Yes" to Item Number 16., provide your physical address below. Physical Address 17.a. In Care Of Name 17.b. Street Number and Name 17.c. Apt. Ste. Flr. 3. 17.d. City or Town 4. 17.e. State 17.f. ZIP Code 5. Height Weight Feet Inches Pounds Eye Color (Select only one box) Black Gray Maroon Blue Green Pink Brown Hazel Unknown/Other Additional Information About You 18. Are you in removal, deportation, or rescission proceedings? Yes Was a fee paid to anyone other than an attorney in connection with this petition? Yes No 6. 19. No Hair Color (Select only one box) Bald (No hair) Brown Sandy Black Gray White Blond Red Unknown/Other 20. Have you ever been arrested, detained, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance (excluding traffic regulations), or committed any crime which you were not arrested in the United States or abroad? Yes No If you answered "Yes" to Item Number 20., provide a detailed explanation in Part 11. Additional Information or on a separate sheet of paper, and refer to the What Initial Evidence Is Required section of the Form I-751 instructions to determine what criminal history document to include with your petition. Form I-751 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 11 Part 3. Basis for Petition Joint Filing My conditional residence is based on my marriage or my parent's marriage to a U.S. citizen or lawful permanent resident, and I am filing this joint petition together with (Select only one box): 1.a. 1.b. My spouse. My parent's spouse because I am unable to be included in a joint petition filed by my parent and my parent's spouse. Other Information 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. 4. Date of Birth (mm/dd/yyyy) U.S. Social Security Number (if any) OR (Select all applicable boxes in the next section.) 5. A-Number (if any) A- Waiver or Individual Filing Request My conditional residence is based on my marriage or my parent's marriage to a U.S. citizen or lawful permanent resident, I am unable to file a joint petition with my spouse or my parent's spouse, because: 1.c. 1.d. My spouse is deceased. My marriage was entered in good faith, but the marriage was terminated through divorce or annulment. I entered the marriage in good faith, and, during the marriage, I was battered, or was the subject of extreme cruelty, by my U.S. citizen or lawful permanent resident spouse. My parent entered the marriage in good faith, and, during the marriage, I was battered, or was subjected to extreme cruelty, by my parent's U.S. citizen or lawful permanent resident spouse or by my conditional resident parent. The termination of my status and removal from the United States would result in an extreme hardship. 6.c. City or Town 6.d. State 6.f. Province 6.e. ZIP Code Physical Address 6.a. Street Number and Name 6.b. Apt. Ste. Flr. 1.e. 6.g. Postal Code 6.h. Country 1.f. Part 5. Information About Your Children Provide information on all of your children. If you need extra space to complete this section, use the space provided in Part 11. Additional Information. Child 1 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. Date of Birth (mm/dd/yyyy) A-Number (if any) 1.g. Part 4. Information About the U.S. Citizen or Lawful Permanent Resident Spouse. If Filing as a Child Separately, Information About the U.S. Citizen or Lawful Permanent Resident Stepparent Through Whom You Gained Your Condit