Form I-129F Edition 07/23/20
Page 9 of 13
Part 3. Other Information (continued)
Homicide, murder, manslaughter, rape, abusive sexual
contact, sexual exploitation, incest, torture, trafficking,
peonage, holding hostage, involuntary servitude, slave
trade, kidnapping, abduction, unlawful criminal restraint,
false imprisonment, or an attempt to commit any of these
crimes?
2.b.
Yes No
Three or more arrests or convictions, not from a single
act, for crimes relating to a controlled substance or
alcohol?
2.c.
Yes No
NOTE: If you were ever arrested or convicted of any of the
specified crimes, you must submit certified copies of all court
and police records showing the charges and disposition for
every arrest or conviction. You must do so even if your records
were sealed, expunged, or otherwise cleared, and regardless of
whether anyone, including a judge, law enforcement officer, or
attorney, informed you that you no longer have a criminal
record. If you need extra space to complete this section, use the
space provided in Part 8. Additional Information.
If you have provided information about a conviction for a crime
listed in Item Numbers 2.a. - 2.c. and you were being battered
or subjected to extreme cruelty at the time of your conviction,
select all of the following that apply to you:
3.a. I was acting in self-defense.
3.b. I violated a protection order issued for my own
protection.
3.c. I committed, was arrested for, was convicted of, or
pled guilty to a crime that did not result in serious
bodily injury and there was a connection between the
crime and me having been battered or subjected to
extreme cruelty.
Multiple Filer Waiver Request Information
Refer to Part 3. Types of Waivers in the Specific Instructions
section of the Instructions for an explanation of the filing
waivers.
Multiple Filer, No Permanent Restraining Orders or
Convictions for a Specified Offense (General
Waiver)
Indicate which one of the following waivers you are requesting:
Multiple Filer, Prior Permanent Restraining Orders or
Criminal Conviction for Specified Offense
(Extraordinary Circumstances Waiver)
Multiple Filer, Prior Permanent Restraining Order or
Criminal Convictions for Specified Offense Resulting
from Domestic Violence (Mandatory Waiver)
Not applicable, beneficiary is my spouse or I am not
a multiple filer
5.a.
5.b.
5.c.
5.d.
Part 4. Biographic Information
1.
2.
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
Height Feet Inches3.
Have you ever been arrested, cited, charged, indicted,
convicted, fined, or imprisoned for breaking or violating
any law or ordinance in any country, excluding traffic
violations (unless a traffic violation was alcohol- or drug-
related or involved a fine of $500 or more)?
4.a.
NoYes
If the answer to Item Number 4.a. is "Yes," provide
information about each of those arrests, citations, charges,
indictments, convictions, fines, or imprisonments in the
space below. If you were the subject of an order of
protection or restraining order and believe you are the
victim, please explain those circumstances and provide
any evidence to support your claims. Include the dates
and outcomes. If you need extra space to complete this
section, use the space provided in Part 8. Additional
Information.
4.b.
4. Weight Pounds
Black Brown
Green
Maroon
Pink
HazelGray
Blue
5. Eye Color (Select only one box)
Unknown/Other
Hair Color (Select only one box) 6.
Black
Brown Red
White
Unknown/
Other
Sandy
Gray
BlondBald (No hair)