Fillable Form I-90: Application to Replace Permanent Resident Card (American Immigration Lawyers Association)

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Form I-90: Application to Replace Permanent Resident Card (American Immigration Lawyers Association)

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Form I-90 Edition 07/23/20
DRAFT
NOT FOR
PRODUCTION
07/29/2020
Page 1 of 7
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 07/31/2022
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
USCIS Online Account Number2.
►
6.g.
Province
A-
(USPS ZIP Code Lookup)
If your name has legally changed since the issuance of your
Permanent Resident Card, provide your name exactly as it
is printed on your current Permanent Resident Card.
NOTE: Include 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
To be completed
by an attorney
or BIA-accredited
representative.
Select this box if
Form G-28 is
attached to
represent the
applicant.
Attorney State Bar Number
Attorney or Accredited Representative
USCIS Online Account Number
Form I-90 Edition 07/23/20
DRAFT
NOT FOR
PRODUCTION
07/29/2020
Page 2 of 7
Part 1. Information About You (continued)
Street Number
and Name
8.a.
In Care Of Name
8.b.
8.c.
Apt. Flr.Ste.
8.d. City or Town
8.h. Postal Code
8.i. Country
8.e. State 8.f. ZIP Code
8.g. Province
Alternate or Safe Mailing Address
If you filed an adjustment of status application based on the
Violence Against Women Act (VAWA) or as a human
trafficking victim (T nonimmigrant), or victim of a qualifying
crime (U nonimmigrant) and you do not want USCIS to send
notices about this application to your home, you may provide a
safe mailing address. If you are applying as a special immigrant
juvenile, you may provide an alternate mailing address.
11.
12.
10.
Date of Birth (mm/dd/yyyy)
City/Town/Village
of Birth
Country of Birth
13.
Gender
Male Female
►
14.
Class of Admission
Date of Admission (mm/dd/yyyy)
U.S. Social Security Number
15.
16.
Parent 1 Legal Name
Middle Name
18.c.
Given Name
(First Name)
18.b.
Family Name
(Last Name)
18.a.
Parent 2 Legal Name
17.a. Family Name
(Last Name)
17.b. Given Name
(First Name)
17.c.
Middle Name
9.a. Street Number
and Name
9.c. City or Town
9.d. State 9.e. ZIP Code
9.b.
Apt. Flr.Ste.
Provide this information only if different than mailing address.
Country 9.h.
Postal Code 9.g.
Province9.f.
Port-of-Entry Commuters
All commuters (those who currently have commuter status and
those who are taking up commuter status) who provided a
foreign mailing address in Item Numbers 6.a. - 6.i., need to
provide the U.S. port-of-entry (POE) where you will pick up
your card:
NOTE: If the city or town has more than one POE, include
additional information (such as an airport, bridge, or tunnel
name) to assist U.S. Citizenship and Immigration Services
(USCIS) in identifying which POE to mail your card.
7. City or Town and State
Physical Address
Additional Information
Form I-90 Edition 07/23/20
DRAFT
NOT FOR
PRODUCTION
07/29/2020
Page 3 of 7
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. (Provide a detailed explanation of the error in
the space provided in Part 7. Additional
Information and return your existing 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 or my
card has incorrect data and the error was not caused
by DHS. (Provide a detailed explanation of the
biographic information that changed or the error in
the space provided in Part 7. Additional
Information, and include appropriate documentary
evidence that reflects the change or new data.)
Section B. Complete this section only if you are a conditional
permanent resident. If your conditional permanent resident status
is expiring within the next 90 days, then do not file this
application. (See the What is the Purpose of Form I-90 section
of the Form I-90 Instructions for further information.)
3.a. My previous card has been lost, stolen, or destroyed.
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:
Part 3. Processing Information
Part 2. Application Type
2.d.
My existing card has incorrect data because of
Department of Homeland Security (DHS) error.
(Provide a detailed explanation of the error in the
space provided in Part 7. Additional Information
and return your existing card with incorrect data
along with this application.)
Reason for Application (Select only one box)
Section A. (Complete this section only if you are 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.
2.e.
My name or other biographic information has legally
changed since issuance of my existing card or my card
has incorrect data and the error was not caused by
DHS. (Provide a detailed explanation of the
biographic information that changed or the error in the
space provided in Part 7. Additional Information,
and include appropriate documentary evidence that
reflects the change or new data.)
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.
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.k. However, if
your card has expired, you must select reason 2.f.
2.h.1.
I am a permanent resident who is taking up commuter
status.
2.j.
I am applying to replace my current Permanent
Resident Card for any other reason that is not
specified above. Provide a detailed explanation of the
reason you are applying to replace your card in the
space provided in Part 7. Additional Information.
2.k.
I have a prior edition of the alien registration card.
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 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.)
NOTE: If your conditional permanent resident status is
expiring within the next 90 days, then do not file this
application. (See the What is the Purpose of Form I-90
section of the Form I-90 Instructions for further information.)
Form I-90 Edition 07/23/20
DRAFT
NOT FOR
PRODUCTION
07/29/2020
Page 4 of 7
White
Hair Color (Select only one box) 17.
Black
Brown Red
Unknown/Other
Sandy
Gray
BlondBald (No hair)
Black
Brown
Maroon
Pink
HazelGreen
Blue
16.
Eye Color (Select only one box)
Unknown/Other
Gray
Part 3. Processing Information (continued)
5.
Yes
7.
Yes
9.
Yes
11. Were you ever out of regular employment in the U.S. for
a continuous period of six months or more while you held
commuter status?
NoYes
No
Since you were granted permanent resident status, have
you ever been employed outside the United States, other
than while you held commuter status?
10.
Since you were granted permanent resident status, have
you ever had a residence outside the United States, other
than while you held commuter status?
NoYes
No
Since you were granted permanent resident status, have
you ever been absent from the United States for a
continuous period of one year or more?
8.
Since you were granted permanent resident status, have
you ever been absent from the United States for a
continuous period for more than 180 days but less than
one year?
NoYes
No
Since you were granted permanent resident status, have
you ever been determined by a judge to have abandoned
your permanent resident status?
6.
Since you were granted permanent resident status, have
you ever filed or signed a Form I-407, Record of
Abandonment of Lawful Permanent Resident Status, or
any other document indicating you have abandoned your
permanent resident status?
NoYes
NOTE: Only answer Item Number 11. if you hold or have
held commuter status.
12.
13.
Height
15. Weight
Feet Inches
14.
Pounds
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
Asian
Black or African American
Answer Item Numbers 4. - 11. If you answer "Yes" to any
question (or if you answer “No,” but are unsure of your answer),
provide a detailed explanation in the space provided in Part 7.
Additional Information.
4. Have you ever been in exclusion, deportation, or removal
proceedings or ordered removed from the United States?
NoYes
Port-of-Entry where admitted to the United States:3.a.1.
Complete Item Numbers 3.a. and 3.a.1. 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:
Part 4. 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 section.
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.
,
American Indian or Alaska Native
White
Form I-90 Edition 07/23/20
DRAFT
NOT FOR
PRODUCTION
07/29/2020
Page 5 of 7
I am fluent in English and ,
Part 4. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
Date of Signature (mm/dd/yyyy)6.b.
Applicant's Signature 6.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.
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 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:
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 and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
I furthermore 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 law.
Applicant's Daytime Telephone Number3.
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.
1)
I reviewed and provided or authorized all of the
information in my application;
2)
All of this information was complete, true, and correct
at the time of filing.
3)
I understood all of the information contained in, and
submitted with, my application; and
Applicant's Contact Information
Part 5. Interpreter's Contact Information,
Certification, and Signature
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)
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 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.
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.
Form I-90 Edition 07/23/20
DRAFT
NOT FOR
PRODUCTION
07/29/2020
Page 6 of 7
Part 5. Interpreter's Contact Information,
Certification, and Signature (continued)
Part 6. 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
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature 7.a.
Interpreter's Signature
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)
Preparer's Certification
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, you may need 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
Form I-90 Edition 07/23/20
DRAFT
NOT FOR
PRODUCTION
07/29/2020
Page 7 of 7
3.d.
6.a.
Page Number 6.b. Part Number 6.c. Item Number
6.d.
5.d.
Part 7. 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. Type or print your name and A-Number 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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.
3.a. Page Number
3.b. Part Number 3.c. Item Number
5.a.
Page Number 5.b. Part Number 5.c. Item Number
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.
►
A-
A-Number
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Form I-90: Application to Replace Permanent Resident Card (American Immigration Lawyers Association)

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Completed 25 June 2021

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