Fillable Ins Form I-90 I90

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Ins Form I-90 I90

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Form I-90 02/27/17 N
For
USCIS
Use
Only
Application to Replace Permanent Resident Card
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-90
OMB No. 1615-0082
Expires 07/31/2019
START HERE - Type or print in black ink.►
Part 1. Information About You
Alien Registration Number (A-Number)
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.
4.
Middle Name
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.)
1.
Street Number
and Name
Mailing Address
6.a.
In Care Of Name
6.b.
6.c.
Apt. Flr.Ste.
6.d. City or Town
6.h.
Postal Code
6.i. Country
6.e.
State
6.f.
ZIP Code
Class of Admission
Applicant Interviewed
Action BlockReceipt
Date:
Remarks
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
USCIS Online Account Number (if any)2.
►
6.g.
Province
Page 1 of 7
A-
Physical Address
7.a. Street Number
and Name
7.c. City or Town
7.d.
State
7.e.
ZIP Code
7.b.
Apt. Flr.Ste.
Provide this information only if different than mailing address.
Country 7.h.
Postal Code
7.g.
Province
7.f.
Form I-90 02/27/17 N
9.
10.
Part 1. Information About You (continued)
8.
Date of Birth (mm/dd/yyyy)
City/Town/Village
of Birth
Country of Birth
►
14.
13.
Class of Admission
Date of Admission
(mm/dd/yyyy)
U.S. Social Security Number (if any)
15.
2.e.
My name or other biographic information has been
legally changed since issuance of my existing card.
2.f.
My existing card has already expired or will expire
within six months.
2.g.1.
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.)
2.g.2.
2.d.
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.)
Mother's Name
Father's Name
11.
Given Name
(First Name)
12.
Given Name
(First Name)
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.
My previous card has been lost, stolen, or destroyed.
2.b.
My previous card was issued but never received.
2.c.
My existing card has been mutilated.
Additional Information
16.
Gender
Male Female
Part 2. Application Type
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.
Page 2 of 7
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.
Lawful Permanent Resident (Proceed to Section. A.)
1.b.
Permanent Resident - In Commuter Status
(Proceed to Section. A.)
1.c.
Conditional Permanent Resident
(Proceed to Section B.)
2.j.
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.
2.h.1.a.
2.h.2.
I am a commuter who is taking up actual residence in
the United States.
2.i.
I have been automatically converted to lawful
permanent resident status.
My Port-of-Entry (POE) into the United States will be:
2.h.1.
I am a permanent resident who is taking up commuter
status.
City or Town and State
Form I-90 02/27/17 N
1.
2.
Location where you applied for an immigrant visa or
adjustment of status:
Location where your immigrant visa was issued or USCIS
office where you were granted adjustment of status:
4.
5.
Have you ever been in exclusion, deportation, or removal
proceedings or ordered removed from the United States?
NoYes
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?
NoYes
NOTE: If you answered "Yes" to Item Numbers 4. or 5.
above, provide a detailed explanation in the space provided in
Part 8. Additional Information.
6.
7.
Height
9. Weight
Feet Inches
8.
Pounds
3.b.
My previous card was issued but never received.
3.c. My existing card has been mutilated.
3.d.
My existing card has incorrect data because of DHS
error. (Attach your existing permanent resident card
with incorrect data along with this application.)
3.e.
My name or other biographic information has legally
changed since the issuance of my existing card.
Part 3. Processing Information
Part 2. Application Type (continued)
Section B. (To be used only by a conditional permanent resident.)
3.a. My previous card has been lost, stolen, or destroyed.
Port-of-Entry where admitted to the United States:3.a.1.
Biographic Information
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select only one box)
Race (Select all applicable boxes)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Asian
Black or African American
Black Brown
Maroon
Pink
HazelGreen
Blue
10.
Eye Color (Select only one box)
Unknown/Other
Gray
Page 3 of 7
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.)
City or Town and State
3.a. Destination in the United States at time of admission
White
Hair Color (Select only one box) 11.
Black
Brown Red
Unknown/Other
Sandy
Gray
BlondBald (No hair)
Part 4. Accommodations for Individuals with
Disabilities and/or Impairments (Read the
information in the Form I-90 Instructions before
completing this part.)
1. Are you requesting an accommodation because of your
disabilities and/or impairments?
NoYes
1.a.
I am deaf or hard of hearing and request the
following accommodation (If you are requesting a
sign-language interpreter, indicate for which
language (for example, American Sign Language)):
If you answered "Yes," select any applicable boxes:
NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
Form I-90 02/27/17 N
1.b.
I am blind or have low vision and request the
following accommodation:
Page 4 of 7
1.c.
I have another type of disability and/or impairment
(Describe the nature of your disability and/or
impairment and the accommodation you are
requesting):
Part 5. Applicant's Statement, Contact
Information, Certification, and Signature
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
NOTE: Read the Penalties section of the Form I-90
Instructions before completing this part.
Applicant's Statement
1.b.
The interpreter named in Part 6. read to me every
question and instruction on this application and my
answer to every question in
a language in which I am fluent and I understood
everything.
,
2.
At my request, the preparer named in Part 7.,
prepared this application for me based only upon
information I provided or authorized.
,
Applicant's Contact Information
Applicant's Daytime Telephone Number3.
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.
Part 4. Accommodations for Individuals with
Disabilities and/or Impairments (continued)
Applicant's Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any of my records that USCIS may need
to determine my eligibility for the immigration benefit I seek.
I certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I understand all of the
information contained in, and submitted with, my application,
and that all of this information is complete, true, and correct.
I further authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:
1) I reviewed and provided or authorized all of the
information in my application;
2) I understood all of the information contained in, and
submitted with, my application; and
3) All of this information was complete, true, and correct
at the time of filing.
(mm/dd/yyyy)Date of Signature6.b.
Applicant's Signature6.a.
Applicant's Signature
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
Form I-90 02/27/17 N Page 5 of 7
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Provide the following information about the interpreter.
Part 6. Interpreter's Contact Information,
Certification, and Signature
3.h.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
Street Number
and Name
3.a.
Country
3.b. Apt. Flr.Ste.
3.g. Postal Code
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)6.
5. Interpreter's Mobile Telephone Number (if any)
Interpreter's Certification
I certify, under penalty of perjury, that:
which is the same language provided in Part 5., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Certification, and has
verified the accuracy of every answer.
I am fluent in English and ,
(mm/dd/yyyy)Date of Signature7.b.
Interpreter's Signature7.a.
Interpreter's Signature
Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Full Name
1.a.
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
1.b.
Provide the following information about the preparer.
Preparer's Business or Organization Name (if any)2.
Preparer's Mailing Address
3.h.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Province
Street Number
and Name
3.a.
Country
3.b. Apt. Flr.Ste.
3.g. Postal Code
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Mobile Telephone Number (if any)
Form I-90 02/27/17 N
Preparer's Certification
Page 6 of 7
I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.
7.a.
7.b.
preparation of this application.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend beyond the
Preparer's Statement
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this application, you may be obliged to
submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this application.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
information is complete, true, and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.
Preparer's Signature
Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Form I-90 02/27/17 N
3.d.
6.a.
Page Number 6.b. Part Number 6.c. Item Number
6.d.
5.d.
Part 8. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Include 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.
Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2. A-Number (if any)
3.a. Page Number 3.b. Part Number 3.c. Item Number
5.a.
Page Number 5.b. Part Number 5.c. Item Number
Page 7 of 7
A-
4.a.
Page Number 4.b. Part Number 4.c. Item Number
4.d.
7.a.
Page Number 7.b. Part Number 7.c. Item Number
7.d.
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Completed 16 July 2020

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