Fillable Form I-955: Application for Commonwealth of the Northern Mariana Islands (CNMI) Long-Term Resident Status (USCIS)

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Form I-955: Application for Commonwealth of the Northern Mariana Islands (CNMI) Long-Term Resident Status (USCIS)

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Page 1 of 15Form I-955 12/26/19
Application for Commonwealth of the Northern Mariana
Islands (CNMI) Long-Term Resident Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in black ink.►
Part 1. Information About You
Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Other Names You Have Ever Used Since Birth
(if applicable)
Middle Name
3.c.
Given Name
(First Name)
3.b.
Family Name
(Last Name)
3.a.
Middle Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c.
NOTE: Provide all other names you have ever used, including
your family name at birth, other legal names, nicknames,
aliases, and assumed names. If you need extra space to
complete this section, use the space provided in Part 14.
Additional Information.
CNMI Mailing Address
4.a.
In Care of Name (if any)
4.d. City or Town
4.e. State 4.f. ZIP Code
Street Number
and Name
4.b.
4.c. Apt. Flr.Ste.
USCIS
Form I-955
CNMI Physical Address
5.a.
In Care of Name (if any)
5.d. City or Town
5.e. State 5.f. ZIP Code
Street Number
and Name
5.b.
5.c. Apt. Flr.Ste.
Other Information About You
Date of Birth (mm/dd/yyyy)10.
6.
►
A-
Alien Registration Number (A-Number) (if any)
USCIS Online Account Number (if any)
11. U.S. Social Security Number (if any)
7.
►
8. Country of Birth
9. Country of Citizenship or Nationality
►
Date of Last Arrival into the CNMI (mm/dd/yyyy)12.
Information About Your Most Recent Entry Into
the CNMI
Passport Number (if any)
15. Travel Document Number (if any)
14.
13.
Form I-94 Arrival-Departure Record Number (if any)
►
Page 2 of 15Form I-955 12/26/19
Part 1. Information About You (continued)
Part 2. Information About This Application
Basis for Classification (select all that apply):
Current Nonimmigrant Status
17.a.
Information About Your Most Recent Entry Into
the CNMI (continued)
Expiration Date (mm/dd/yyyy)17.b.
Applicant was, on November 27, 2009, a permanent
resident of the CNMI (as defined in section 4303 of
title 3 of the Northern Mariana Islands
Commonwealth Code, in effect on May 8, 2008).
Applicant is the spouse or child (as defined in the
INA section 101(b)(1) (8 U.S.C. 1101(b)(1)) of a
permanent resident of the CNMI (as defined in
section 4303 of title 3 of the Northern Mariana
Islands Commonwealth Code, in effect on May 8,
2008).
Applicant had a grant of parole on December 31,
2018, under the former parole program for certain
in-home caregivers administered by USCIS.
1.f.
1.e. Applicant was, on November 27, 2011, a spouse,
child, or parent of a United States citizen,
notwithstanding the age of the United States citizen,
and continues to have such family relationship.
1.d.
1.c.
Applicant is the spouse or child (as defined in the
Immigration and Nationality Act (INA) section
101(b)(1) (8 U.S.C. 1101(b)(1)) of an individual born
in the Northern Mariana Islands between January 1,
1974 and January 9, 1978.
1.b.
1.a. Applicant was born in the Northern Mariana Islands
between January 1, 1974 and January 9, 1978.
Part 3. Additional Information About You
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
16.b.
16.a. Country of Issuance for Passport or Travel Document
1. Have you ever applied for an immigrant visa to obtain
permanent resident status at a U.S. Embassy or U.S.
Consulate abroad?
Yes No
If you answered “Yes” to Item Number 1., complete Item
Numbers 2.a. - 4. below. If you need extra space to complete
this section, use the space provided in Part 14. Additional
Information.
Location of U.S. Embassy or U.S. Consulate
2.a.
City or Town
2.b. Country
Date of Decision (mm/dd/yyyy)
Decision (for example, approval, refused, denied,
withdrawn)
3.
4.
5. Have you ever filed a Form I-485, Application to
Register Permanent Residence or Adjust Status?
Yes No
If you answered “Yes” to Item Number 5., complete
Item Numbers 6.a. - 7.b. below. If you need extra space
to complete this section, use the space provided in
Part 14. Additional Information.
►
6. USCIS receipt number of Form I-485
Date of Decision (mm/dd/yyyy)
Decision (for example, approval, refused, denied,
withdrawn)
7.a
7.b
Address History
Provide physical addresses for everywhere you have lived since
November 28, 2009. Provide your current address first. If you
need extra space to complete this section, use the space
provided in Part 14. Additional Information.
8.c.
8.d.
City or Town
ZIP Code8.e.State
8.a.
8.b.
Street Number
and Name
Apt. Ste. Flr.
Province8.f.
8.h.
8.g.
Country
Postal Code
Physical Address 1 (current address)
Page 3 of 15Form I-955 12/26/19
10.c.
10.d.
City or Town
ZIP Code10.e.State
10.a.
10.b.
Street Number
and Name
Apt. Ste. Flr.
Province10.f.
10.h.
10.g.
Country
Postal Code
Physical Address 2
Part 3. Additional Information About You
(continued)
Dates of Residence
9.a. From (mm/dd/yyyy)
9.b. To (mm/dd/yyyy)
Dates of Residence
11.a. From (mm/dd/yyyy)
11.b. To (mm/dd/yyyy)
12.c.
12.d.
City or Town
ZIP Code10.e.State
12.a.
12.b.
Street Number
and Name
Apt. Ste. Flr.
Province12.f.
12.h.
12.g.
Country
Postal Code
Physical Address 3
Dates of Residence
13.a. From (mm/dd/yyyy)
13.b. To (mm/dd/yyyy)
Part 4. Information About Your Parents
Information About Your Parent 1
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Parent 1's Legal Name
3. Date of Birth (mm/dd/yyyy)
4. Sex Male Female
7. Current City or Town of Residence (if living)
City or Town of Birth5.
6. Country of Birth
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Parent 1's Name at Birth (if different than above)
8. Current Country of Residence (if living)
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c. Middle Name
Parent 2's Legal Name
11. Date of Birth (mm/dd/yyyy)
12. Sex Male Female
10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)
10.c. Middle Name
Parent 2's Name at Birth (if different than above)
Information About Your Parent 2
Page 4 of 15Form I-955 12/26/19
Part 4. Information About Your Parents
(continued)
15. Current City or Town of Residence (if living)
City or Town of Birth13.
14. Country of Birth
16. Current Country of Residence (if living)
Part 5. Information About Your Marital History
1. What is your current marital status?
Widowed
Legally Separated
Marriage Annulled
Single, Never Married Married Divorced
How many times have you been married (including
anulled marriages and marriages to the same person)?
2.
►
Information About Current Marriage (including if
you are legally separated)
5. Current Spouse's Date of Birth (mm/dd/yyyy)
A-Number (if any)4.
A-
►
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
If you are currently married, provide the following information
about your current spouse.
Current Spouse's Legal Name
6. Date of Marriage to Current Spouse (mm/dd/yyyy)
7.a.
State or Province7.b.
City or Town
7.c. Country
Current Spouse's Place of Birth
8.a. City or Town
8.c. Country
Place of Marriage to Current Spouse
Information About Prior Marriages (if any)
If you have been married before, whether in the United States or
in any other country, provide the following information about
your prior spouse. If you have had more than one previous
marriage, use the space provided in Part 14. Additional
Information to provide the information below.
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c. Middle Name
Prior Spouse's Legal Name (provide family name before
marriage)
10. Prior Spouse's Date of Birth (mm/dd/yyyy)
11. Date of Marriage to Prior Spouse (mm/dd/yyyy)
12.a.
State or Province12.b.
City or Town
12.c. Country
Place of Marriage to Prior Spouse
State or Province8.b.
Page 5 of 15Form I-955 12/26/19
13.
Date Marriage with Prior Spouse Legally Ended
(mm/dd/yyyy)
Part 5. Information About Your Marital History
(continued)
14.a.
State or Province14.b.
City or Town
14.c. Country
Place Where Marriage with Prior Spouse Legally Ended
Part 6. Information About Your Children
1. Indicate the total number of ALL living children
(including adult sons and daughters) that you have.
NOTE: The term “children” includes all biological or legally
adopted children, as well as current stepchildren, of any age,
whether born in the United States or other countries, married or
unmarried, living with you or elsewhere and includes any
missing children and those born to you outside of marriage.
Provide the following information for each of your children. If
you have more than three children, use the space provided in
Part 14. Additional Information.
2.a.
Child 1
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
4. Date of Birth (mm/dd/yyyy)
5. Country of Birth
Current Legal Name
2.b.
2.c.
3.
►
A-
A-Number (if any)
6.a.
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
Child 2
6.b.
6.c.
8. Date of Birth (mm/dd/yyyy)
9. Country of Birth
7.
►
A-
A-Number (if any)
10.a.
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
Child 3
10.b.
10.c.
12. Date of Birth (mm/dd/yyyy)
13. Country of Birth
11.
►
A-
A-Number (if any)
Current Legal Name
Current Legal Name
Part 7. 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
4. Weight
Feet Inches3.
Pounds
Page 6 of 15Form I-955 12/26/19
Black Brown
Maroon
Pink
HazelGreen
Blue
5.
Eye Color (Select only one box)
Unknown/Other
Gray
White
Hair Color (Select only one box) 6.
Black
Brown Red
Unknown/Other
Sandy
Gray
BlondBald (No hair)
Part 7. Biographic Information (continued)
Organization 1
2. Name of Organization
From (mm/dd/yyyy)5.a.
To (mm/dd/yyyy)5.b.
1.
Have you EVER been a member of, involved in, or in
any way associated with any organization, association,
fund, foundation, party, club, society, or similar group
including any military service?
Yes No
Part 8. General Eligibility and Inadmissibility
Grounds
If you answered “Yes” to Item Number 1., complete
Item Numbers 2. - 13.b. below. If you need extra space
to complete this section, use the space provided in
Part 14. Additional Information. If you answered
“No,” but are unsure of your answer, provide an
explanation of the events and circumstances in the space
provided in Part 14. Additional Information.
3.a.
State or Province3.b
City or Town
3.c. Country
4. Nature of Group
Dates of Membership or Dates of Involvement
Organization 2
6. Name of Organization
From (mm/dd/yyyy)9.a.
To (mm/dd/yyyy)9.b.
7.a.
State or Province7.b
City or Town
7.c. Country
8. Nature of Group
Dates of Membership or Dates of Involvement
Organization 3
10. Name of Organization
From (mm/dd/yyyy)13.a.
To (mm/dd/yyyy)13.b.
11.a.
State or Province11.b
City or Town
11.c. Country
12. Nature of Group
Dates of Membership or Dates of Involvement
Answer Item Numbers 14. - 83.b. Choose the answer that you
think is correct. If you answer “Yes” to any questions (or if
you answer “No,” but are unsure of your answer), provide
an explanation of the events and circumstances in the space
provided in Part 14. Additional Information.
14. Have you EVER been denied admission to the United
States?
Yes No
Page 7 of 15Form I-955 12/26/19
Yes No
Have you EVER been arrested, cited, charged, or
detained for any reason by any law enforcement official
(including but not limited to any U.S. immigration official
or any official of the U.S. armed forces or U.S. Coast
Guard)?
24.
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
16. Have you EVER worked in the United States without
authorization?
Yes No
15. Have you EVER been denied a visa to the United States?
Yes No
17. Have you EVER violated the terms or conditons of your
nonimmigrant status?
Yes No
18. Are you presently or have you EVER been in removal,
exclusion, rescission, or deportation proceedings?
Yes No
19. Have you EVER been issued a final order of exclusion,
deportation, or removal?
Yes No
20. Have you EVER had a prior final order of exclusion,
deportation, or removal reinstated?
Yes No
21. Have you EVER held lawful permanent resident status
which was later rescinded?
Yes No
22. Have you EVER been granted voluntary departure by an
immigration officer or an immigration judge but failed to
depart within the allotted time?
Yes No
23. Have you EVER applied for any kind of relief or
protection from removal, exclusion, or deportation?
Yes No
Criminal Acts and Violations
For Item Numbers 24. - 44., you must answer “Yes” to any
question that applies to you, even if your records were sealed or
otherwise cleared, or even if anyone, including a judge, law
enforcement officer, or attorney, told you that you no longer
have a record. You must also answer “Yes” to the following
questions whether the action or offense occurred here in the
United States or anywhere else in the world. If you answer
“Yes” to Item Numbers 24. - 44., use the space provided in
Part 14. Additional Information to provide an explanation
that includes why you were arrested, cited, detained, or charged;
where you were arrested, cited, detained, or charged; when
(date) the event occurred; and the outcome or disposition (for
example, no charges filed, charges dismissed, jail, probation,
community service).
Yes No
Have you EVER committed a crime of any kind (even if
you were not arrested, cited, charged with, or tried for that
crime)?
25.
Yes No
Have you EVER pled guilty to or been convicted of a
crime or offense (even if the violation was subsequently
expunged or sealed by a court, or if you were granted a
pardon, amnesty, a rehabilitation decree, or other act of
clemency)?
26.
NOTE: If you were the beneficiary of a pardon, amnesty,
a rehabilitation decree, or other act of clemency, provide
documentation of that post-conviction action.
Yes No
Have you EVER been ordered punished by a judge or had
conditions imposed on you that restrained your liberty
(such as a prison sentence, suspended sentence, house
arrest, parole, alternative sentencing, drug or alcohol
treatment, rehabilitative programs or classes, probation, or
community service)?
27.
Yes No
Have you EVER been a defendant or the accused in a
criminal proceeding (including pre-trial diversion,
deferred prosecution, deferred adjudication, or any
withheld adjudication)?
28.
Yes No
Have you EVER violated (or attempted or conspired to
violate) any controlled substance law or regulation of a
state, the United States, or a foreign country?
29.
Yes No
Have you EVER been convicted of two or more offenses
(other than purely political offenses) for which the
combined sentences to confinement were five years or
more?
30.
Yes No
Have you EVER illicitly (illegally) trafficked or
benefited from the trafficking of any controlled
substances, such as chemicals, illegal drugs, or narcotics?
31.
Yes No
Have you EVER knowingly aided, abetted, assisted,
conspired, or colluded in the illicit trafficking of any
illegal narcotic or other controlled substances?
32.
Yes No
Are you the spouse, son, or daughter of a foreign national
who illicitly trafficked or aided (or otherwise abetted,
assisted, conspired, or colluded) in the illicit trafficking of
a controlled substance, such as chemicals, illegal drugs, or
narcotics and you obtained, within the last five years, any
financial or other benefit from the illegal activity of your
spouse or parent, although you knew or reasonably should
have known that the financial or other benefit resulted
from the illicit activity of your spouse or parent?
33.
Page 8 of 15Form I-955 12/26/19
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
34. Have you EVER engaged in prostitution?
Yes No
35.
Have you EVER directly or indirectly procured (or
attempted to procure) or imported prostitutes or persons
for the purpose of prostitution?
Yes No
36.
Have you EVER received any proceeds or money from
prostitution?
Yes No
37.
Do you intend to engage in illegal gambling or any other
form of commercialized vice, such as prostitution,
bootlegging, or the sale of child pornography?
Yes No
38.
Have you EVER exercised immunity (diplomatic or
otherwise) to avoid being prosecuted for a criminal
offense in the United States?
Yes No
39.
Have you EVER, while serving as a foreign government
official, been responsible for or directly carried out
violations of religious freedoms?
Yes No
40.
Have you EVER induced by force, fraud, or coercion (or
otherwise been involved in) the trafficking of persons for
commercial sex acts?
Yes No
41.
Have you EVER trafficked a person into involuntary
servitude, peonage, debt bondage, or slavery? Trafficking
includes recruiting, harboring, transporting, providing, or
obtaining a person for labor or services through the use of
force, fraud, or coercion.
Yes No
42.
Have you EVER knowingly aided, abetted, assisted,
conspired, or colluded with others in trafficking persons
for commercial sex acts or involuntary servitude,
peonage, debt bondage, or slavery?
Yes No
43.
Are you the spouse, son or daughter of a foreign national
who engaged in the trafficking of persons and have
received or obtained, within the last 5 years, any financial
or other benefits from the illicit activity of your spouse or
your parent, although you knew or reasonably should
have known that this benefit resulted from the illicit
activity of your spouse or parent?
Yes No
44.
Have you EVER engaged in money laundering or have
you EVER knowingly aided, assisted, conspired, or
colluded with others in money laundering or do you seek
to enter the United States to engage in such activity?
Yes No
Security and Related
Do you intend to:
45.a.
Engage in any activity that violates or evades any law
relating to espionage (including spying) or sabotage in the
United States?
Yes No
45.b.
Engage in any activity in the United States that violates
or evades any law prohibiting the export from the
United States of goods, technology, or sensitive
information?
Yes No
45.c.
Engage in any activity whose purpose includes opposing,
controlling, or overthrowing the U.S. Government by
force, violence, or other unlawful means while in the
United States?
Yes No
45.d.
Engage in any activity that could endanger the welfare,
safety, or security of the United States?
Yes No
45.e.
Engage in any other unlawful activity?
Yes No
46.
Are you engaged in or, upon your entry into the United
States, do you intend to engage in any activity that could
have potentially serious adverse foreign policy
consequences for the United States?
Yes No
Have you EVER:
47.a.
Committed, threatened to commit, attempted to commit,
conspired to commit, incited, endorsed, advocated,
planned, or prepared any of the following: hijacking,
sabotage, kidnapping, political assassination, or use of a
weapon or explosive to harm another individual or cause
substantial damage to property?
Yes No
47.b.
Participated in, or been a member of, a group or
organization that did any of the activities described in
Item Number 47.a.?
Yes No
47.c.
Recruited members or asked for money or things of value
for a group or organization that did any of the activities
described in Item Number 47.a.?
Yes No
47.d.
Provided money, a thing of value, services or labor, or
any other assistance or support for any of the activities
described in Item Number 47.a.?
Yes No
47.e.
Provided money, a thing of value, services or labor, or
any other assistance or support for an individual, group,
or organization who did any of the activities described in
Item Number 47.a.?
Yes No
48.
Have you EVER received any type of military,
paramilitary, or weapons training?
Yes No
Page 9 of 15Form I-955 12/26/19
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
49.
Do you intend to engage in any of the activities listed in
any part of Item Numbers 47.a. - 48.?
Yes No
NOTE: If you answered “Yes” to any part of Item
Numbers 45.a. - 49., explain what you did, including the
dates and location of the circumstances, or what you
intend to do in the space provided in Part 14. Additional
Information.
50.a.
Are you the spouse or child of an individual who EVER:
Committed, threatened to commit, attempted to commit,
conspired to commit, incited, endorsed, advocated,
planned, or prepared any of the following: hijacking,
sabotage, kidnapping, political assassination, or use of a
weapon or explosive to harm another individual or cause
substantial damage to property?
Yes No
50.b.
Participated in, or been a member or a representative of a
group or organization that did any of the activities
described in Item Number 50.a.?
Yes No
50.c.
Recruited members, or asked for money or things of
value, for a group or organization that did any of the
activities described in Item Number 50.a.?
Yes No
50.d.
Provided money, a thing of value, services or labor, or
any other assistance or support for any of the activities
described in Item Number 50.a.?
Yes No
50.e.
Provided money, a thing of value, services or labor, or
any other assistance or support to an individual, group, or
organization who did any of the activities described in
Item Number 50.a.?
Yes No
50.f.
Received any type of military, paramilitary, or weapons
training from a group or organization that did any of the
activities described in Item Number 50.a.?
Yes No
NOTE: If you answered “Yes” to any part of Item
Number 50., explain the relationship and what occurred,
including the dates and location of the circumstances, in
the space provided in Part 14. Additional Information.
51. Have you EVER assisted or participated in selling,
providing, or transporting weapons to any person who, to
your knowledge, used them against another person?
Yes No
52. Have you EVER worked, volunteered, or otherwise
served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes No
53. Have you EVER been a member of, assisted, or
participated in any group, unit, or organization of any
kind in which you or other persons used any type of
weapon against any person or threatened to do so?
Yes No
54. Have you EVER served in, been a member of, assisted,
or participated in any military unit, paramilitary unit,
police unit, self-defense unit, vigilante unit, rebel group,
guerilla group, militia, insurgent organization, or any
other armed group?
Yes No
55. Have you EVER been a member of, or in any way
affiliated with, the Communist Party or any other
totalitarian party (in the United States or abroad)?
Yes No
56. During the period from March 23, 1933 to May 8, 1945,
did you ever order, incite, assist, or otherwise participate
in the persecution of any person because of race, religion,
national origin, or political opinion, in association with
either the Nazi government of Germany or any
organization or government associated or allied with the
Nazi government of Germany?
Yes No
Have you EVER ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:
57.a. Acts involving torture or genocide?
Yes No
57.b. Killing any person?
Yes No
57.c. Intentionally and severely injuring any person?
Yes No
57.d.
Engaging in any kind of sexual contact or relations with
any person who did not consent or was unable to consent,
or was being forced or threatened?
Yes No
57.e.
Limiting or denying any person's ability to exercise
religious beliefs?
Yes No
58.
Have you EVER recruited, enlisted, conscripted, or used
any person under 15 years of age to serve in or help an
armed force or group?
Yes No
59.
Have you EVER used any person under 15 years of age
to take part in hostilities, or to help or provide services to
people in combat?
Yes No
NOTE: If you answered “Yes” to any part of Item Numbers
51. - 59., explain what occurred, including the dates and
location of the circumstances, in the space provided in Part 14.
Additional Information.
Page 10 of 15Form I-955 12/26/19
Part 8. General Eligibility and Inadmissibility
Grounds (continued)
Public Assistance
60.
Have you received public assistance in the United States
from any source, including the U.S. Government or any
state, county, city, or municipality (other than emergency
medical treatment)?
Yes No
61.
Are you likely to receive public assistance in the future in
the United States from any source, including the U.S.
Government or any state, county, city, or municipality
(other than emergency medical treatment)?
Yes No
Illegal Entries and Other Immigration Violations
62.a.
Have you EVER failed or refused to attend or to remain
in attendance at any removal proceeding filed against you
on or after April 1, 1997?
Yes No
62.b.
If your answer to Item Number 62.a. is “Yes,” do you
believe you had reasonable cause?
Yes No
62.c.
If your answer to Item Number 62.b. is “Yes,”attach a
written statement explaining why you had reasonable
cause.
63.
Have you EVER submitted fraudulent or counterfeit
documentation to any U.S. Government official to obtain
or attempt to obtain any immigration benefit, including a
visa or entry into the United States?
Yes No
64.
Have you EVER lied about, concealed, or misrepresented
any information on an application or petition to obtain a
visa, other documentation required for entry into the
United States, admission to the United States, or any other
kind of immigration benefit?
Yes No
65.
Have you EVER falsely claimed to be a U.S. citizen (in
writing or any other way)?
Yes No
66.
Have you EVER been a stowaway on a vessel or aircraft
arriving in the United States?
Yes No
67.
Have you EVER knowingly encouraged, induced,
assisted, abetted, or aided any foreign national to enter or
to try to enter the United States illegally (alien
smuggling)?
Yes No
68.
Are you under a final order of civil penalty for violating
INA section 274C for use of fraudulent documents?
Yes No
Removal, Unlawful Presence, or Illegal Reentry
After Previous Immigration Violations
69.
Have you EVER been excluded, deported, or removed
from the United States or have you ever departed the
United States on your own after having been ordered
excluded, deported, or removed from the United States?
Yes No
70.
Have you EVER entered the United States without being
inspected and admitted or paroled?
Yes No
Since April 1, 1997, have you been unlawfully present in the
United States:
71.a.
For more than 180 days but less than 1 year, and then
departed the United States?
Yes No
71.b.
For one year or more and then departed the United States?
Yes No
NOTE: You were unlawfully present in the United States if
you entered the United States without being inspected and
admitted or inspected and paroled, or if you legally entered the
United States but you stayed longer than permitted.
Since April 1, 1997, have you EVER reentered or attempted to
reenter the United States without being inspected and admitted
or paroled after:
72.a.
Having been unlawfully present in the United States for
more than one year in the aggregate?
Yes No
72.b.
Having been deported, excluded, or removed from the
United States?
Yes No
Health Related
73.
Do you have a communicable disease of public health
significance? (A list of communicable diseases of public
health significance can be found in the Form I-955
Instructions.)
Yes No
74.
Have you received all required vaccinations in accordance
with U.S. law? (A list of vaccinations can be found in the
Form I-955 Instructions.)
Yes No
76.
Are you, or have you ever been, a drug abuser or addict
(as described in Health and Human Services regulations at
42 CFR 34)?
Yes No
75.
Do you have, or have you had, a physical or mental
disorder and behavior (or a history of behavior that is
likely to recur) associated with the disorder, which has
posed or may pose a threat to the property, safety, or
welfare of yourself or others?
Yes No
Page 11 of 15Form I-955 12/26/19
Miscellaneous Conduct
77.
Do you plan to practice polygamy in the United States?
Yes No
78.
Are you accompanying another foreign national who
requires your protection or guardianship but who is
inadmissible after being certified by a medical officer as
being helpless from sickness, physical or mental
disability, or infancy, as described in INA section 232(c)?
Yes No
79.
Have you EVER assisted in detaining, retaining, or
withholding custody of a U.S. citizen child outside the
United States from a U.S. citizen who has been granted
custody of the child?
Yes No
80.
Have you EVER voted in violation of any Federal, state,
or local constitutional provision, statute, ordinance, or
regulation in the United States?
Yes No
81.
Have you EVER renounced U.S. citizenship to avoid
being taxed by the United States?
Yes No
Have you EVER:
82.a.
Applied for exemption or discharge from training or
service in the U.S. armed forces or in the U.S. National
Security Training Corps on the ground that you are a
foreign national?
Yes No
82.b.
Been relieved or discharged from such training or service
on the ground that you are a foreign national?
Yes No
82.c.
Been convicted of desertion from the U.S. armed forces?
Yes No
83.a.
Have you EVER left or remained outside the United
States to avoid or evade training or service in the U.S.
armed forces in time of war or a period declared by the
President to be a national emergency?
Yes No
83.b.
If your answer to Item Number 83.a. is “Yes,” what was
your nationality or immigration status immediately before
you left (for example, U.S. citizen or national, lawful
permanent resident, nonimmigrant, parolee, present
without admission or parole, or any other status)?
Part 9. Accommodations for Individuals With
Disabilities and/or Impairments
NOTE: Read the information in the Form I-955 Instructions
before completing this part.
1.
Are you requesting an accommodation because of your
disabilities and/or impairments?
Yes No
If you answered “Yes” to Item Number 1., select all applicable
boxes in Item Numbers 2.a. - 2.c. and provide an answer.
2.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).)
2.b.
I am blind or have low vision and request the
following accommodation:
2.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 10. Applicant's Statement, Contact
Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-955
Instructions before completing this section.
Applicant's Statement
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.
1.b.
The interpreter named in Part 11. 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 12.,
,
prepared this application for me based only upon
information I provided or authorized.
Page 12 of 15Form I-955 12/26/19
Part 10. Applicant's Statement, Contact
Information, Certification, and Signature
(continued)
Applicant's Contact Information
3. Applicant's Daytime Telephone Number
4. Applicant's Mobile Telephone Number (if any)
5. Applicant's Email Address (if any)
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.
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the
information in my request;
2) I understood all of the information contained in, and
submitted with, my request; and
I certify, under penalty of perjury, that all of the information in
my application 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
application and that all of this information is complete, true, and
correct.
Applicant's Signature
6.a. Applicant's Signature
6.b. Date of Signature (mm/dd/yyyy)
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.
Part 11. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2. Interpreter's Business or Organization Name (if any)
Interpreter's Mailing Address
3.a. Street Number
and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
5. Interpreter's Mobile Telephone Number (if any)
6. Interpreter's Email Address (if any)
Page 13 of 15Form I-955 12/26/19
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 10., 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
Declaration and Certification, and has verified the accuracy of
every answer.
Interpreter's Signature
7.a. Interpreter's Signature
7.b. Date of Signature (mm/dd/yyyy)
Part 11. Interpreter's Contact Information,
Certification, and Signature (continued)
Part 12. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
2. Preparer's Business or Organization Name (if any)
Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt. Ste. Flr.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. Country
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Mobile Telephone Number (if any)
6. Preparer's Email Address (if any)
Preparer's Statement
7.a.
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.b.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends does not extend beyond the
preparation of this application.
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.
Page 14 of 15Form I-955 12/26/19
Part 12. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Preparer's Certification
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 Declaration and 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
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Part 13. Signature at Interview
I swear (affirm) and certify under penalty of perjury under the
laws of the United States of America that I know that the
contents of this Form I-955, Application for CNMI Long-Term
Resident Status, subscribed by me, including the corrections
made to this application numbered through ,
are complete, true, and correct. All additional pages submitted
by me with this Form I-955, on numbered pages
through , are complete, true, and correct. All
documents submitted at this interview were provided by me
and are complete, true, and correct.
Subscribed to and sworn to (affirmed) before me:
USCIS Officer's Printed Name or Stamp
Date of Signature (mm/dd/yyyy)
Applicant's Signature
USCIS Officer's Signature
NOTE: Do not complete Part 13. until the USCIS Officer
instructs you to do so at the interview.
Page 15 of 15Form I-955 12/26/19
Part 14. 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 (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.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.
A-Number
►
A-
3.a.
Page Number 3.b. Part Number 3.c. Item Number
3.d.
4.a.
Page Number 4.b. Part Number 4.c. Item Number
4.d.
5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
6.a.
Page Number
6.b.
Part Number
6.c.
Item Number
6.d.
7.a.
Page Number
7.b.
Part Number
7.c.
Item Number
7.d.
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Form I-955: Application for Commonwealth of the Northern Mariana Islands (CNMI) Long-Term Resident Status (USCIS)

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Completed 18 September 2020

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