Form I-90 02/27/17 N
I am blind or have low vision and request the
Page 4 of 7
I have another type of disability and/or impairment
(Describe the nature of your disability and/or
impairment and the accommodation you are
Part 5. Applicant's Statement, Contact
Information, Certification, and Signature
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
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.
NOTE: Read the Penalties section of the Form I-90
Instructions before completing this part.
The interpreter named in Part 6. 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
At my request, the preparer named in Part 7.,
prepared this application for me based only upon
information I provided or authorized.
Applicant's Contact Information
Applicant's Daytime Telephone Number3.
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.
Part 4. Accommodations for Individuals with
Disabilities and/or Impairments (continued)
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 of my records that USCIS may need
to determine my eligibility for the immigration benefit I seek.
I certify, under penalty of perjury, that I provided or authorized
all of the information in my application, I understand all of the
information contained in, and submitted with, my application,
and that all of this information is complete, true, and correct.
I further 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 laws.
I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:
1) I reviewed and provided or authorized all of the
information in my application;
2) I understood all of the information contained in, and
submitted with, my application; and
3) All of this information was complete, true, and correct
at the time of filing.
(mm/dd/yyyy)Date of Signature6.b.
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.