Block 1:
Block 6:
Privacy Act Notice. Our legal right to ask for this information is in 8 U.S.C. 1184. All the information provided on this form, including
addresses, are protected by the Privacy Act and the Freedom of Information Act. This information will not be released in any form
whatsoever to a third party, other than another government agency, who requests it without a court order or without your written consent, or
in the case of a child, the written consent of the parent or legal guardian who filed the form on the child's behalf.
Block 2:
Block 3:
Check the block or blocks that best describe your education
before coming to the United States. Also, check the block or
blocks that best describe how and where you have learned
English.
Block 5:
Block 7:
Check the block that best describes your ability to use English.
Block 8:
Check as many types of public assistance as you have received
or someone has received on your behalf. Indicate the month and
year the assistance started and stopped. If you are still receiving
assistance, write "present" in the block headed "To (mm/yyyy),"
noting month/year.
do, such as "machine operator," "nurse" or "chemist." If you
have not worked at all since coming to the United States, write
"none." At the bottom of the block enter your major occupation
before coming to the United States. If you did not work before
coming to the United States, enter "none."
Block 4:
Reporting Burden. An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection
of information unless it displays a currently valid OMB control number. This collection of information is estimated to average from 10
minutesper response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
thiscollection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory
Management Division, 111 Massachusetts Avenue, N.W. Washington, DC 20529, OMB No. 1615-0070. Do not mail your completed
application to this address.
Form I-643 (Rev. 05/19/06) Y Page 2
Purpose of This Form. Refugees and asylees should submit this Form I-643 when filing an application for adjustment of status.
Although the information requested on Form I-643 will not affect the adjudication of the adjustment application, your application will not be
considered as completely filed unless you submit this form. The data collected on this form will be used by U.S. Department of Health and
Human Services to compile and analyze statistics relating to refugees and asylees. The form will not be retained by U.S. Citizenship and
Immigration Services (USCIS). NOTE: USCIS is comprised of the offices of the former Immigration and Naturalization
Service (INS).
How to Complete the Form.
Instructions to USCIS Officer
Data Unit, Office of Refugee Resettlement
Department Of Health And Human Services
370 L'Enfant Promenade S. W., (6th Floor)
Washington, D. C. 20447
After this form has been completed, forward it directly to the address as shown below: (If you are mailing a small number of
forms, they may be folded so that the address shows through a #20 window envelope.)
(To the Applicant - Type or print plainly in black ink.)
Instructions
This form should be fully completed by a refugee or asylee, age 16 years or older. Representatives of applicants younger than 16 should
only complete Blocks 1 and 2.
Enter your name, the date on which you are completing
this form and your Alien Registration Number on the first
line. On the second line, enter your country of birth and
your country of citizenship. On the third line, enter your
native language, your date of birth and your telephonenumber.
Enter your current address on the fourth line.
Fill in your three (3) most recent cities and states of
residence in the United States in order, starting with your
current place of residence. If you have not lived in three (3)
different cities since you entered the United States, write "none"
on as many lines as appropriate.
Show the total number of people living in your household and the
number currently employed. Fill in the first line
for yourself, then list any other persons who live in your
household. If more than five (5) persons live with you, attach a
separate page listing the others and provide the information
requested.
Enter the information about all jobs you have held since coming to
the United States, starting with your current or most recent job.
Under "Job Title" write the term that best describes the work you
If you have had any training or education in the United States,
check the block or blocks that best describe your training and
enter your major course of study. If you have not had any
training in the United States, enter "none."
