DO NOT WRITE BELOW THE FOLLOWING LINE
The consular officer will assist you in answering item 45.
DO NOT SIGN this form until instructed to do so by the consular officer
45. I claim to be:
This Form May be Obtained Free at Consular Offices of
The United States of America
DS-230 Part II
Page 4 of 4
I understand that I am required to surrender my visa to the United States Immigration Officer at the place where I apply to enter the United States, and that the
possession of a visa does not entitle me to enter the United States if at that time I am found to be inadmissible under the immigration laws.
I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may subject me to permanent
exclusion from the United States and, if I am admitted to the United States, may subject me to criminal prosecution and/or deportation.
I, the undersigned applicant for a United States immigrant visa, do solemnly swear (or affirm) that all statements which appear in this application, consisting
of Form DS-230 Part I and Part II combined, have been made by me, including the answers to items 1 through 45 inclusive, and that they are true and complete
to the best of my knowledge and belief. I do further swear (or affirm) that, if admitted into the United States, I will not engage in activities which would be
prejudicial to the public interest, or endanger the welfare, safety, or security of the United States; in activities which would be prohibited by the laws of the
United States relating to espionage, sabotage, public disorder, or in other activities subversive to the national security; in any activity a purpose of which is the
opposition to or the control, or overthrow of, the Government of the United States, by force, violence, or other unconstitutional means.
I understand that completion of this form by persons required by law to register with the Selective Service System (males 18 through 25 years of age)
constitutes such registration in accordance with the Military Selective Service Act.
Signature of Applicant
Subscribed and sworn to before me this
day of at:
Consular Officer
An alien who is permanently ineligible for U.S. citizenship; or who departed the United States to evade military service
in time of war.
41. Have you ever been charged, arrested or convicted of any offense or crime? (If answer is Yes, please explain)
42. Have you ever been refused admission to the United States at a port-of-entry? (If answer is Yes, please explain)
Yes No
43a. Have you ever applied for a Social Security Number (SSN)?
Yes
Give the number
43b. Consent to Disclosure: I authorize disclosure of information
from this form to the Department of Homeland Security (DHS), the
Social Security Administration (SSA), such other U.S. Government
agencies as may be required for the purpose of assigning me an SSN
and issuing me a Social Security card, and I authorize the SSA to share
my SSN with the INS.
No
44. Were you assisted in completing this application?
Yes
No
(If answer is Yes, give name and address of person assisting you, indicating whether relative, friend, travel agent, attorney, or other)
A Family-Sponsored Immigrant
An Employment-Based Immigrant
A Diversity Immigrant
A Special Category (Specify)
I derive foreign state chargeability
under Sec. 202(b) through my
(Returning resident, Hong Kong, Tibetan, Private Legislation, etc.)
Preference
Numerical limitation
(foreign state)
An alien who is coming to the United States to practice polygamy; who withholds custody of a U.S. citizen child
outside the United States from a person granted legal custody by a U.S. court or intentionally assists another person to
do so; who has voted in the United States in violation of any law or regulation; or who renounced U.S. citizenship to
avoid taxation.
An alien who is a former exchange visitor who has not fulfilled the 2-year foreign residence requirement.
An alien determined by the Attorney General to have knowingly made a frivolous application for asylum.
An alien who has ordered, carried out or materially assisted in extrajudicial and political killings and other acts of
violence against the Haitian people; who has directly or indirectly assisted or supported any of the groups in Colombia
known as FARC, ELN, or AUC; who through abuse of a governmental or political position has converted for personal
gain, confiscated or expropriated property in Cuba, a claim to which is owned by a national of the United States, has
trafficked in such property or has been complicit in such conversion, has committed similar acts in another country, or
is the spouse, minor child or agent of an alien who has committed such acts; who has been directly involved in the
establishment or enforcement of population controls forcing a woman to undergo an abortion against her free choice or
a man or a woman to undergo sterilization against his or her free choice; or who has disclosed or trafficked in
confidential U.S. business information obtained in connection with U.S. participation in the Chemical Weapons
Convention or is the spouse, minor child or agent of such a person; or who has ever engaged in the recruitment of or the use
of child solders.
An alien who was previously ordered removed within the last 5 years or ordered removed a second time within the last
20 years; who was previously unlawfully present and ordered removed within the last 10 years or ordered removed a
second time within the last 20 years; who was convicted of an aggravated felony and ordered removed; who was
previously unlawfully present in the United States for more than 180 days but less than one year who voluntarily
departed within the last 3 years; or who was unlawfully present for more than one year or an aggregate of one year
within the last 10 years.
Yes No
Yes No
NoYes
Yes No
Yes No
Yes No
Yes No
Yes No
The applicant's response does not limit or restrict the Government's
ability to obtain his or her SSN, or other information on this form, for
enforcement or other purposes as authorized by law.
NoYes
g.
h.
i.
j.
k.
l.
Would you like to receive a replacement
card? (You must answer YES to question
43b. to receive a card.)
Do you want the Social
Security Administration to
assign you a SSN and issue a
card? (You must answer YES
to question 43b. to receive a
number and a card.)
Yes No
