8. Previous Immigration Record
First Name1. Family Name Middle Name
2. Other Names Used, Aliases (If Married Woman, Give Maiden Name)
3. Current Home Address and Telephone Number
4. Place of Birth (City, Province, Country) 5. Date of Birth (mm-dd-yyyy)
6. Marital Status
Married Single (Never Married) Widowed Divorced
If married, information about spouse
a. Name (Last, First, MI)
b. Address
c. Place of Birth
d. Date of Birth (mm-dd-yyyy)
e. U.S. Residence Status, if any (U.S. Citizen, Legal Permanent Resident, Etc.)
f. Date of Marriage to You (mm-dd-yyyy)
7. List Below All Close Family Members in the United States (Continue on Separate Page if Necessary.)
Full Name Relationship Resident Status Place of Residence
a. DHS "A" Number b. Immigration Category
c. Previous Immigrant Visa d. Adjustment of Status
Date of Issue (mm-dd-yyyy)
Date of Adjustment of Status
with DHS (IF ANY) (mm-dd-yyyy)
Place of Adjustment of
Status with DHS (IF ANY)
Place of Issue
e. Initial Entry into the United as Lawful Permanent Resident f. Last Entry into the United States as Lawful Permanent Resident
Date of Entry (mm-dd-yyyy) Port of Entry
Date of Entry (mm-dd-yyyy) Port of Entry
U.S. Department of State
OMB CONTROL NO.1405-0091
EXPIRATION Date: 05/31/2023
Page 1 of 3
This is an application for Special Immigrant Status under Section 101(a)(27)(A) of the Immigration and Nationality Act, for lawfully admitted permanent
residents who are returning from a temporary visit abroad. To qualify you must submit with this application evidence that:
Applicants must submit evidence with this application to support the above requirements, including proof of lawful permanent residence
(Examples: Form I-151, I-551, Reentry Permit, etc.), dates of travel outside of the United States (Examples: airline tickets, passport stamps, etc.), proof
of ties to the United States and intention to return (Examples: tax returns, and evidence of economic, family and social ties to the United States), and
proof a protracted stay was for reasons beyond the applicant's control (Examples: medical incapacitation, employment with a U.S. company,
accompanying a U.S. citizen spouse, etc.) All documents will be returned to you.
9. Most Recent Departure from the United States
Date of Departure (mm-dd-yyyy) Destination
(1) You had the status of an alien lawfully admitted for permanent residence at the time of departure from the United States;
(2) You departed from the United States with the intention of returning and you have not abandoned this intention; and
(3) You are returning to the United States from a temporary visit abroad and, if the stay abroad was protracted, this was caused by reasons
beyond your control and for which you are not responsible.
10. What continuing ties have you maintained with the United States? What efforts have you made to avoid abandoning your permanent resident
status in the United States?
13. Have you been employed outside of the United States since your most recent departure?
11. Reasons for not returning to the United States until time of this application.
12. List below all periods that you have lived outside of the United States for six months or longer since your initial entry into the United States as a
permanent resident.
If "Yes" complete the following:
Name of Employer Address From (mm-dd-yyyy) To (mm-dd-yyyy)
14. I wish to return to the United States on or about
Date (mm-dd-yyyy)
15. By typing my name in the field below, I swear or affirm that all statements which appear on this application are true and complete to the best of my
knowledge and belief. I understand that any false or misleading statement or willful concealment of a material fact may subject me to permanent
exclusion from the United States. I understand that if this application for special immigrant status is approved, I must apply for an immigrant visa within
six months from the date of approval.
Approved 101(a)(27)(A)
Concur Do NOT Concur
Dates (mm-dd-yyyy)
From To
Date (mm-dd-yyyy)
Name of Applicant
Type Name of Reviewing Officer
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
Will add electronic signature when converted to pdf
Signature of Reviewing Officer
Type Name of Consular Officer
Will add electronic signature when converted to pdf
Signature of Consular Officer
Yes No
DS-117 Page 2 of 3
AUTHORITIES: The information is sought pursuant to 8 U.S.C. § 1101 et seq, 8 U.S.C. §§ 1201-1202, and by regulations issued pursuant to 8 CFR
211.1 and 22 CFR 42.22.
PURPOSE: The information solicited on this form will be used to determine your eligibility for returning resident status.
ROUTINE USES: The information on this form maybe shared with federal, state, and local government agencies, members of Congress, and officials of
foreign governments in accordance with certain approved routine uses. More information on the Routine Uses for the system can be found in the
System of Records Notice State-39, Visa Records.
DISCLOSURE: Providing this information is mandatory. Failure to provide the information requested on this form may result in the applicant's inability to
receive returning resident status.
Privacy Act Statements
INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation,
amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be
made available to a court which certifies that the information contained in such records is needed in a case pending before the court.
Confidentiality Statement
Page 3 of 3DS-117