Fillable Form I-485: Supplement A to Form I-485, Adjustment (American Immigration Lawyers Association)

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Form I-485: Supplement A to Form I-485, Adjustment (American Immigration Lawyers Association)

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Form I-485 Supplement A 10/15/19
Page 1 of 4
Supplement A to Form I-485,
Adjustment of Status Under Section 245(i)
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-485
OMB No. 1615-0023
Expires 10/31/2021
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Your Current Legal Name
Part 1. Information About You
U.S. Mailing Address
NOTE: Use Supplement A to Form I-485, Adjustment of Status Under INA Section 245(i) (Supplement A), only if you are applying
to adjust status to that of a lawful permanent resident under the Immigration and Nationality Act (INA) section 245(i). You may file
Supplement A only if you are filing your Form I-485, Application to Register Permanent Residence or Adjust Status, at the same time
or if you previously filed your Form I-485 and it remains pending.
START HERE - Type or print in black ink.►
City or Town2.d.
ZIP Code2.f.State2.e.
Street Number
and Name
2.b.
2.c. Apt.
Flr.Ste.
2.a. In Care Of Name (if any)
►
A-
Alien Registration Number (A-Number) (if any)3.
►
4. USCIS Online Account Number (if any)
5. Date of Birth (mm/dd/yyyy)
6. Country of Birth
7. Country of Citizenship or Nationality
You are or were the principal beneficiary of an
immigrant petition or application for permanent labor
certification filed on or before January 14, 1998.
1.a.
You are or were the principal beneficiary of an
immigrant petition or application for permanent labor
certification filed on or after January 15, 1998, and
on or before April 30, 2001, and you were physically
present in the United States on December 21, 2000.
1.b.
You are or were the derivative beneficiary of an
immigrant petition or application for permanent labor
certification filed on or before January 14, 1998.
1.c.
You are or were the derivative beneficiary of an
immigrant petition or application for permanent labor
certification filed on or after January 15, 1998, and
on or before April 30, 2001, and the principal
beneficiary was physically present in the United
States on December 21, 2000.
1.d.
You are currently the spouse applying to accompany
or follow-to-join your spouse OR the child
(unmarried and under 21 years of age) applying to
accompany or follow-to-join your parent described in
Item Numbers 1.a. - 1.d.
1.e.
2.
Provide the following information about the immigrant petition
or application for permanent labor certification filed on or
before April 30, 2001 that qualifies you to adjust status under
INA section 245(i).
Receipt Number of Petition (if any)
Part 2. Eligibility
You claim eligibility to adjust status under INA section 245(i)
because (Select only one box):
Basis of INA Section 245(i) Eligibility
Qualifying Petition or Application
Other Information
(USPS ZIP Code Lookup)
Form I-485 Supplement A 10/15/19
Page 2 of 4
Part 2. Eligibility (continued)
Type or print the family-based, employment-based,
special immigrant, or Diversity Visa immigrant category
you selected on Form I-485, Part 2. Application Type or
Filing Category, Item Numbers 2.a. - 8.e.
5.
Information on Principal Beneficiary of Petition or Application
3.b.
3.c.
3.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Immigrant Category
Part 3. Bars to Adjustment
You last entered the United States without being
admitted or paroled after inspection by an
immigration officer.
You last entered the United States as a nonimmigrant
crewman.
You are now employed or have ever been employed
in the United States without authorization.
You are not in lawful immigration status on the date
of filing your application for adjustment of status.
You have ever failed to continuously maintain a
lawful status since entry into the United States, unless
your failure to maintain status was through no fault of
your own or for technical reasons.
You were last admitted to the United States in transit
without a visa.
You were last admitted to the United States as a
nonimmigrant visitor without a visa under the Guam
and Commonwealth of the Northern Mariana Islands
Visa Waiver Program, and you are not a Canadian
citizen.
You are applying to adjust under INA section 245(i) because
one or more of the following bars to adjustment apply to you
(Select all applicable boxes):
1.a.
1.b.
1.c.
1.d.
1.e.
1.f.
1.g.
You were last admitted to the United States as a
nonimmigrant visitor without a visa under the Visa
Waiver Program (See
travel.state.gov/content/visas/
english/visit/visa-waiver-program.html).
1.h.
You are seeking employment-based adjustment of
status and you are not maintaining a lawful
nonimmigrant status on the date of filing your
application for adjustment of status.
You have ever violated the terms of your
nonimmigrant status.
1.i.
1.j.
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Supplement A
Instructions before completing this part. You must file
Supplement A while in the United States.
I can read and understand English, and I have read
and understand every question and instruction on this
supplement and my answer to every question.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Applicant's Statement
The interpreter named in Part 5. read to me every
question and instruction on this supplement and my
answer to every question in
1.b.
a language in which I am fluent, and I understood
everything.
,
2. At my request, the preparer named in Part 6.,
prepared this supplement for me based only upon
information I provided or authorized.
,
Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)
4.
►
A-
Principal Applicant's A-Number (if any)4.
Form I-485 Supplement A 10/15/19
Page 3 of 4
Part 4. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
I furthermore authorize release of information contained in this
supplement, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I certify, under penalty of perjury, that all of the information in
my supplement and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
supplement and that all of this information is complete, true,
and correct.
Applicant's Signature
Date of Signature (mm/dd/yyyy)6.b.
Applicant's Signature (sign in ink)6.a.
NOTE TO ALL APPLICANTS: If you do not completely fill
out this supplement or fail to submit required documents listed
in the Instructions, USCIS may deny your Form I-485.
Interpreter's Business or Organization Name (if any)
2.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Part 5. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Contact Information
Interpreter's Daytime Telephone Number4.
Interpreter's Email Address (if any)6.
Interpreter's Mobile Telephone Number (if any)
5.
Interpreter's Certification
I am fluent in English and
I certify, under penalty of perjury, that:
,
Interpreter's Signature
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature (sign in ink)
7.a.
which is the same language specified in Part 4., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this supplement and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
supplement, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
Province
Postal Code
3.g.
3.h. Country
Applicant's Declaration and Certification
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
that U.S. Citizenship and Immigration Services (USCIS) may
require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
Form I-485 Supplement A 10/15/19
Page 4 of 4
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.g.
3.h. Country
Province
Preparer's Contact Information
Preparer's Mobile Telephone Number (if any)5.
Preparer's Daytime Telephone Number4.
Preparer's Email Address (if any)6.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, with this
supplement.
I am an attorney or accredited representative and
my representation of the applicant in this case
extends does not extend beyond the
7.b.
preparation of this supplement.
Preparer's Statement
I am not an attorney or accredited representative but
have prepared this supplement on behalf of the
applicant and with the applicant's consent.
7.a.
Preparer's Signature
8.a.
Preparer's Signature (sign in ink)
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this supplement at the request of the applicant. The
applicant then reviewed this completed supplement and
informed me that he or she understands all of the information
contained in, and submitted with, his or her supplement,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this supplement based only on information that the
applicant provided to me or authorized me to obtain or use.
Preparer's Given Name (First Name)1.b.
2. Preparer's Business or Organization Name (if any)
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Provide the following information about the preparer.
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Supplement, if Other Than the Applicant
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Form I-485: Supplement A to Form I-485, Adjustment (American Immigration Lawyers Association)

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Completed 29 July 2020

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