Fillable I-817 Form I-817

Fill Online, Printable, Fillable, Blank I-817 Form I-817 Form

Use Fill to complete blank online USCIS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

I-817 Form I-817

On average this form takes 88 minutes to complete

The I-817 Form I-817 form is 18 pages long and contains:

  • 0 signatures
  • 186 check-boxes
  • 264 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your United States Citizenship and Immigration Services documents online.

U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

BROWSE USCIS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form I-817 11/07/17 N Page 1 of 12
For USCIS Use Only
Application for Family Unity Benefits
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-817
OMB No. 1615-0005
Expires 11/30/2019
Remarks
From / / /
To / / /
Action Block
Sent
Received
Relocated
Fee Stamp
Resubmitted
Returned
Initial Application
Valid
Approved Denied
From / / /
To / / /
Request for Extension
Valid
Approved Denied
Part 1. Information About You (Person
Requesting Family Unity Benefits)
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 10.
Additional Information.
3.a.
Family Name
(Last Name)
3.b.
Given Name
(First Name)
3.c.
Middle Name
4.a.
Family Name
(Last Name)
4.b.
Given Name
(First Name)
4.c.
Middle Name
10. Country of C
itizenship or Nationality
9. Country
of Birth
8. Sex Male Female
ZIP Code11.f.State
City or Town
11.e.
11.d
U.S. Mailing Address
11.a. In Care Of Name (if any)
Street Number
and Name
11.b.
11.c. Apt. Flr.Ste.
START HERE - Type or print in black ink.►
To be completed
by an attorney or
BIA-accredited
representative (if any).
Select this box if
Form G-28 is
attached.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
USCIS Online Account Number (if any)7.
►
Alien Registration Number (A-Number) (if any)1.
A-
►
NOTE: You must reside and file Form I-817 while in the United States.
5. Date of Birth (mm/dd/yyyy)
Other Information
U.S. Social Security Number (if any)6.
►
Your Full Name
Other Names Used
Form I-817 11/07/17 N Page 2 of 12
Part 1. Information About You (Person
Requesting Family Unity Benefits) (continued)
Part 3. Basis For Application
1.a.
On May 5, 1988, I was the spouse of an alien who
was legalized under the Immigration and Nationality
Act (INA) section 245A.
1.b.
On May 5, 1988, I was the unmarried child under 21
years of age of an alien who was legalized under INA
section 245A.
I am applying for Family Unity benefits because: (Select
only one box)
1.
2.
Height
4. Weight
Feet Inches
3.
Pounds
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
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)
1.g.
I am the spouse of a person who is eligible for and
has filed or adjusted status under section 1104 of
Public Law (Pub. L.) 106-553, the Legal
Immigration Family Equality (LIFE) Act. I entered
the United States on or before December 1, 1988,
and resided in the United States on that date.
NOTE: To be eligible for Immigration Act of 1990
(IMMACT 90) Family Unity Program benefits, your
qualifying spouse or parent must have maintained his or her
status as a legalized alien or as a U.S. citizen, if he or she
naturalized. If deceased, he or she must have maintained
status until his or her death. For LIFE Act Family Unity, your
spouse or parent must be eligible for adjustment or have
adjusted status under section 1104 of the LIFE Act. If you
previously qualified for LIFE Act Family Unity, you may be
eligible to apply for IMMACT 90 Family Unity Program
Benefits.
2.a.
Initial Family Unity benefits under section 301 of
IMMACT 90.
2.d.
An extension of Family Unity benefits under section
1504 of the LIFE Act Amendments.
2.c.
Initial Family Unity benefits under section 1504 of
the LIFE Act Amendments.
2.b.
An extension of Family Unity benefits under section
301 of IMMACT 90.
I am requesting: (Select only one box)
1.f.
On May 5, 1988, I was the unmarried child under
21 years of age of a person who adjusted status
under section 202 of the Immigration Reform and
Control Act of 1986 (Cuban/Haitian Adjustment).
1.h.
I am the unmarried child under 21 years of age of
a person who had filed an adjustment of status
application or adjusted status under section 1104
of Pub. L. 106-553, the LIFE Act. I entered the
United States on or before December 1, 1988, and
resided in the United States on that date.
1.e.
On May 5, 1988, I was the spouse of a legalized
alien who adjusted status under section 202 of the
Immigration Reform and Control Act of 1986
(Cuban/Haitian Adjustment).
On December 1, 1988, I was the spouse of an alien
who was legalized as a Special Agricultural Worker
under INA section 210.
1.c.
1.d.
On December 1, 1988, I was the unmarried child
under 21 years of age of an alien who was a legalized
alien as a Special Agricultural Worker under INA
section 210.
U.S. Physical Address
12.c.
12.d.
12.a.
12.b.
City or Town
State
12.e.
ZIP Code
Street Number
and Name
Apt. Flr.Ste.
Part 2. Biographic Information
Form I-817 11/07/17 N Page 3 of 12
4. Date of Birth (mm/dd/yyyy)
U.S. Social Security Number (if any)7.
A-Number (if any)5.
8. Sex
Male Female
9. Class of Admission (visitor, student, EWI, etc.)
USCIS Online Account Number (if any)6.
►
Marital Status13.
Married Divorced
Provide the following information about you and your spouse.
14.a. Number of times you have been married (including current
marriage)
14.b. Number of times your spouse has been married (including
spouse's current marriage)
Complete Only if You Are Applying Based on a
Marital Relationship or You Were Previously
Married
If currently married, provide the following information about
your marriage.
15.a.
15.b.
Date of Marriage (mm/dd/yyyy)
City or Town
15.c. State
Country15.e.
15.d. Province
15.g. We are:
15.h. If you selected "Not living together," (select only one box):
Living together
My spouse has died
We are separated
We are divorced
Not living together
15.f. Type of Ceremony:
Religious Civil None
A-
►
►
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Other Names Used
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
Widowed Separated
Information About Your Spouse or Parent
Provide the following information about the legalized alien
through whom you are claiming your eligibility.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
If you need extra space to complete Part 4., use the space
provided in Part 10. Additional Information.
Part 4. Information About Your Relationship
Email Address (if any)12.
Place of Marriage
U.S. Physical Address for Your Spouse or Parent
10.c.
10.d.
City or Town
State
10.e.
ZIP Code
Street Number
and Name
10.a.
10.b. Apt. Flr.Ste.
Daytime Telephone Number (if any)11.
Provide all other names the legalized alien has ever used,
including aliases, maiden name, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
Form I-817 11/07/17 N Page 4 of 12
Information About Your Prior Marriage
Provide the following information about your prior marriages
(if any).
16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)
16.c. Middle Name
17.a. Date of Marriage (if any) (mm/dd/yyyy)
Part 4. Information About Your Relationship
(continued)
City or Town
17.c. State
Country17.e.
17.d. Province
17.b.
17.g.
State17.h.
City or Town
17.f. Date of Termination (mm/dd/yyyy)
Province17.i.
17.j. Country
17.k. Reason for Termination
Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 10. Additional Information.)
Divorce Death Annulment
Place of Prior Marriage
Place of Termination
Information About Your Spouse's Prior Spouse
Provide the following information about your current spouse's
prior marriages (if any).
18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c. Middle Name
Province19.i.
State19.h.
19.j. Country
19.k. Reason for Termination
Divorce
Death Annulment
Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 10. Additional Information.)
19.g.
City or Town
NOTE: If you were previously married, you must complete
Part 4.
, Item Numbers 13. - 19.k.
of this application; complete
all requested information about your prior marriages; and select
the box in Item Number 20. indicating that it is complete.
20.
I have completed Part 4., Item Numbers 13. - 19.k.,
information about my prior marriages (if any).
Country19.e.
19.d. Province
19.f. Date of Termination (mm/dd/yyyy)
Place of Termination
City or Town
19.c. State
19.b.
Place of Marriage
19.a. Date of Marriage (if any) (mm/dd/yyyy)
Form I-817 11/07/17 N Page 5 of 12
Part 4. Information About Your Relationship
(continued)
Complete Only if You Are Applying Based on a
Child/Parent Relationship
Biological father who was not married to my mother
when I was born
Indicate how your parent is related to you (Select only one box)
Biological mother
Biological father who was married to my mother
when I was born
21.a.
21.b.
21.c.
Stepparent - based on marriage to my parent which
occurred before my 18th birthday
21.d.
22.a.
Provide the following information about your marital status.
Married
SeparatedWidowed
Single, Never Married Divorced
Marital Status
Provide the following information.
23.a. Date of Marriage (mm/dd/yyyy)
23.b. City or Town
23.c. State
Country23.e.
23.d. Province
23.f. Type of ceremony: Religious
Civil None
23.g. We are:
Living together Not living together
23.h. If you selected "Not living together," (Select only one box):
My spouse has died
We are separated
We are divorced
Place of Marriage
My adoptive parent had legal custody of me
on May 5, 1988 or December 1, 1988, (as
appropriate), and I resided with him or her for
two years prior to that date.
Adoptive parent (select only one box):
A. The adoption occurred before my 16th birthday.
B.
Yes
NoYes
No
21.e.
If divorced or widowed, provide the following information.
24.b. City or Town
24.c. State
Country24.e.
24.d. Province
24.a. Date of Marriage (mm/dd/yyyy)
Place Marriage Ended
Part 5. Other Information
1.
Have you EVER applied before for the Family Unity
Program?
NoYes
If you answered "Yes," provide the following information.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Name Under Which You Applied
2.d.
2.e.
City or Town
2.f. Date Filed (mm/dd/yyyy)
2.g.
U.S. Citizenship and Immigration Services (USCIS) (or
former Immigration and Naturalization Service (INS))
action taken on case
State
Approved Denied
3.a. At the time of your last entry into the United States, you
(Select only one box):
Were inspected and admitted
Were inspected and paroled
Entered without inspection
Place Where Application Was Filed
3.b. Date of Last Arrival (mm/dd/yyyy)
Form I-94 Arrival-Departure Record Number 3.c.
►
Form I-817 11/07/17 N Page 6 of 12
Part 5. Other Information (continued)
Passport Number3.d.
Travel Document Number3.e.
3.f.
Country of Issuance for Passport or Travel Document
3.g.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Current or Most Recent Immigration Status
3.h.
3.i. Date Status Expires (mm/dd/yyyy)
Date Continuous U.S. Residence Began (mm/dd/yyyy)3.j.
Provide the U.S. address where you lived on May 5, 1988 (INA
section 245A or Cuban Haitian Adjustment Act) or December
1, 1988 (INA section 210 or LIFE Act).
Street Number
and Name
4.a.
4.b. Apt. Flr.Ste.
If you are submitting separate applications for Family Unity
benefits at this time for other relatives, provide the following
information about those other relatives.
4.c.
4.d.
City or Town
State
4.e.
ZIP Code
5.a.
Family Name
(Last Name)
5.b.
Given Name
(First Name)
5.c.
A-Number (if any)5.d.
5.e. Relationship to Applicant
Middle Name
A-
►
NOTE: If you need extra space to complete an answer in Item
Numbers 5.a. - 24.f., use the space provided in Part 10.
Additional Information..
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c.
Middle Name
A-Number (if any)6.d.
6.e. Relationship to Applicant
A-
►
7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)
7.c.
A-Number (if any)7.d.
7.e. Relationship to Applicant
Middle Name
A-
►
8.a. Family Name
(Last Name)
8.b. Given Name
(First Name)
8.c.
A-Number (if any)8.d.
8.e. Relationship to Applicant
9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c.
A-Number (if any)9.d.
9.e. Relationship to Applicant
Middle Name
Middle Name
A-
►
A-
►
10.a.
Family Name
(Last Name)
10.b.
Given Name
(First Name)
10.c.
A-Number (if any)
10.d.
10.e. Relationship to Applicant
Middle Name
A-
►
Form I-817 11/07/17 N Page 7 of 12
Part 5. Other Information (continued)
List all absences from the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Form I-817,
whichever date is later.
11.a.
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
12.b.
12.a.
11.b.
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
13.b.
13.a.
14.b.
14.a.
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
15.b.
15.a.
16.b.
16.a.
17.b.
17.a.
List all residences in the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Family Unity
application (Form I-817), whichever date is later.
18.c. City or Town
18.d.
18.f.
State
From To
Present
Dates of Residence (mm/dd/yyyy)
18.e. ZIP Code
Street Number
and Name
18.a.
18.b. Apt.
Flr.Ste.
Current Residence
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
19.c. City or Town
19.d.
19.f.
State
From To
19.e. ZIP Code
Street Number
and Name
19.a.
19.b. Apt. Flr.Ste.
Previous Residence 1
Dates of Residence (mm/dd/yyyy)
20.c. City or Town
20.d.
20.f.
State 20.e. ZIP Code
Street Number
and Name
20.a.
20.b. Apt. Flr.Ste.
Previous Residence 2
From To
Dates of Residence (mm/dd/yyyy)
21.c. City or Town
Street Number
and Name
21.a.
21.b. Apt. Flr.Ste.
Previous Residence 3
21.d.
21.f.
State 21.e. ZIP Code
From To
22.c. City or Town
22.d.
22.f.
State 22.e. ZIP Code
Street Number
and Name
22.a.
22.b. Apt. Flr.Ste.
Previous Residence 4
From To
Dates of Residence (mm/dd/yyyy)
Dates of Residence (mm/dd/yyyy)
Form I-817 11/07/17 N Page 8 of 12
Part 5. Other Information (continued)
23.c. City or Town
23.d. State 23.e. ZIP Code
Street Number
and Name
23.a.
23.b. Apt. Flr.Ste.
23.f.
Previous Residence 5
From To
Dates of Residence (mm/dd/yyyy)
NOTE: If you need extra space to complete an answer in Item
Numbers 5.a. - 24.f., use the space provided in Part 10.
Additional Information.
Answer Item Numbers 25.a. - 38. If you answer “Yes” to
ANY of the questions, use the space provided in Part 10.
Additional Information to provide an explanation.
25.e. Limiting or denying any person's ability to exercise
religious beliefs?
25.a. Acts involving torture or genocide?
Have you EVER ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:
25.b. Killing any person?
25.c. Intentionally and severely injuring any person?
25.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes
No
Yes No
Yes
No
Yes No
NoYes
24.c. City or Town
24.d.
24.f.
State
Dates of Residence
24.e. ZIP Code
Street Number
and Name
24.a.
24.b. Apt. Flr.Ste.
(mm/dd/yyyy)
Previous Residence 6
From To
Have you EVER:
26.a.
Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, self-
defense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
26.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes No
NoYes
27.
Have you EVER been a member of, assisted in, 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
28.
Have you EVER
assisted or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
29. Have you EVER received any type of military,
paramilitary, or weapons training?
No
Yes No
Yes
30.b.
Been a representative of a terrorist organization or a
member of an organization which you knew or should have
known is a terrorist organization?
Have you EVER in the United States or Abroad:
30.a. Engaged in, conspired to engage in, or intended to engage
in a terrorist activity with intent to cause death or serious
bodily harm?
NoYes
31.
Have you EVER e
ngaged in any activity to violate any
law of the United States related to espionage or sabotage
or to violate or evade any law prohibiting the export from
the United States of goods, technology, or sensitive
information?
Yes No
NoYes
32.a.
Been convicted by a final judgment of a particularly
serious crime?
33.
Have you EVER
been convicted of any offenses for
which the aggregate sentences were five or more years
of confinement?
Yes No
NoYes
32.b. Participated in any other criminal activity which
endangers public safety or national security of the
United States?
NoYes
Have you EVER:
Form I-817 11/07/17 N Page 9 of 12
Part 5. Other Information (continued)
Have you EVER
been ordered deported, excluded, or
removed from the United States as you were inadmissible
at the time of entry or of adjustment of status, or violated
status?
34.
Yes No
Have you
EVER been convicted of a felony crime of
violence that has an element of or attempted use of
physical force against another individual in the course of
committing the offense?
35.
NoYes
36.
Have you EVER
engaged in genocide, or ordered, incited,
assisted or otherwise participated in the persecution of
any person because of race, religion, national origin,
membership in a particular social group, or political
opinion?
Yes No
Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-817
Instructions before completing this part.
At my request, the preparer named in Part 8.,
2.
prepared this application for me based only upon
information I provided or authorized.
,
The interpreter named in Part 7. read to me every
question and instruction on this application and my
answer to every question in
1.b.
a language in which I am fluent, and I understood
everything.
,
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.
Applicant's Statement
Have you EVER
committed a serious nonpolitical crime
outside the United States before you arrived in the United
States?
37.
NoYes
Yes No
Have you EVER
been convicted of a felony or three or
more misdemeanors in the United States?
38.
5.
Applicant's Email Address (if any)
Applicant's Mobile Telephone Number (if any)4.
Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Applicant's Declaration and 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 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:
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 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.
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct at
the time of filing.
Applicant's Signature
6.a.
6.b. Date of Signature (mm/dd/yyyy)
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.
Form I-817 11/07/17 N Page 10 of 12
Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
Interpreter's Business or Organization Name (if any)2.
Part 7. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code3.g.
Province
3.h. Country
Street Number
and Name
3.a.
3.b.
Apt. Flr.Ste.
Interpreter's Daytime Telephone Number
6.
4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
Interpreter's Mobile Telephone Number (if any)
5.
Interpreter's Signature7.a.
7.b.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and ,
which is the same language specified in Part 6., 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.
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing This
Application, if Other Than the Applicant
Preparer's Full Name
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
Preparer's Business or Organization Name (if any)2.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code3.g.
Province
3.h. Country
Street Number
and Name
3.a.
3.b.
Apt. Flr.Ste.
Form I-817 11/07/17 N Page 11 of 12
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing This
Application, if Other Than the Applicant
(continued)
Preparer's Contact Information
Preparer's Daytime Telephone Number
6.
4.
Preparer's Email Address (if any)
Preparer's Mobile Telephone Number (if any)5.
Preparer's Statement
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.
I am not an attorney or accredited representative
but have prepared this application on behalf of the
applicant and with the applicant's consent.
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 application.
7.a.
7.b.
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
Preparer's Signature8.a.
8.b. Date of Signature (mm/dd/yyyy)
Provide your signature below. This signature will be scanned
and duplicated for placement on your Employment Authorization
Document. When signing, make sure that no part of your
signature goes outside the lines of the box.
Part 9. Signature for Placement On Employment
Authorization Document
Signature
Form I-817 11/07/17 N Page 12 of 12
Part 10. Additional Information
3.d.
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.
Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
2. A-Number (if any)
3.a.
Page Number 3.b. Part Number 3.c. Item Number
6.a.
Page Number 6.b. Part Number 6.c. Item Number
6.d.
4.d.
4.a.
Page Number 4.b. Part Number 4.c. Item Number
5.d.
5.a.
Page Number 5.b. Part Number 5.c. Item Number
A-
►
7.a.
Page Number
7.b. Part Number 7.c. Item Number
7.d.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

I-817 Form I-817

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 November 2019

Message

View Audit Log
Print With Audit Log
Duplicate Document