6. Have you ever been ordered removed from the United States?
5. If you entered the United States with an immigrant visa, also complete the following:
(If you were granted adjustment of status, skip this question and proceed to Question 6.)
7. Since you were granted permanent residence, have you ever filed Form I-407,
Abandonment by Alien of Status as Lawful Permanent Resident, or otherwise been
judged to have abandoned your status?
NOTE: If you answered "Yes" to Question 6 or Question 7 above, provide detailed explanation in Part 7.
No
Yes
No
Yes
Form I-90 (Rev. 08/10/09)N Page 3
Part 3. Processing Information
1. Mother's First Name 2. Father's First Name
3. City of residence where you applied for an
immigrant visa or adjustment of status
4. Consulate where immigrant visa or USCIS office
where adjustment of status was granted
a. Destination in United States at time of admission
b. Port of entry where admitted to United States
Part 5. Signature (Read the information on penalties in the instructions before completing this section. You must file this
application while in the United States.)
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with
it is all true and correct. I authorize the release of any information from my records that U.S. Citizenship and Immigration Services
needs to determine eligibility for the benefit I am seeking.
Date Daytime Phone Number
Signature
NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, your application may
be denied.
1. I am deaf or hard of hearing and request the following accommodation(s) (if requesting a sign-language interpreter, indicate
which language (e.g., American Sign Language)):
Are you requesting an accommodation because of your disability and/or impairment?
If you answered "Yes," check any applicable box:
2. I am blind or sight-impaired and request the following accommodation(s):
3. I have another type of disability and/or impairment (describe the nature of your disability(ies) and/or impairment(s) and
accommodation(s) you are requesting):
No
Yes
Part 4. Accommodations for Individuals With Disabilities and Impairments (Read the information in the
instructions before completing this section.)