U.S. Department of State
APPLICATION TO DETERMINE RETURNING RESIDENT STATUS
Single (Never Married)
INSTRUCTIONS
This is an application for Special Immigrant Status under Section 101(a)(27)(A) of the Immigration and Nationality Act, for lawfully admitted permanent
residents who are returning from a temporary visit abroad. To qualify you must submit with this application evidence that:
(1) You had the status of an alien lawfully admitted for permanent residence at the time of departure from the United States;
(2) You departed from the United States with the intention of returning and you have not abandoned this intention; and
(3) You are returning to the United States from a temporary visit abroad and, if the stay abroad was protracted, this was caused by reasons
beyond your control and for which you are not responsible.
Applicants must submit evidence with this application to support the above requirements, including proof of lawful permanent residence
(Examples: Form I-151, I-551, Reentry Permit, etc.), dates of travel outside of the United States (Examples: airline tickets, passport stamps, etc.), proof of
ties to the United States and intention to return (Examples: tax returns, and evidence of economic, family and social ties to the United States), and proof a
protracted stay was for reasons beyond the applicant's control (Examples: medical incapacitation, employment with a U.S. company, accompanying a U.S.
citizen spouse, etc.) All documents will be returned to you.
DS-117
10-2007
Page 1 of 2
9. Most Recent Departure from the United States
*Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary data,
providing the information required, and reviewing the final collection. In accordance with 5 CFR 1320 5(b), persons are not required to respond to the collection of this information unless this form displays a
currently valid OMB control number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/ISS/DIR) Washington, DC 20520.
6. Marital Status
8. Previous Immigration Record
7. List Below All Close Family Members in the United States (Continue on Separate Page if Necessary.)
Full Name Relationship Resident Status Place of Residence
PREVIOUS EDITIONS OBSOLETE
OMB APPROVAL NO. 1405-0091
EXPIRATION DATE 09/30/2010
ESTIMATED BURDEN: 30 MINUTES*
1. Family Name
2. Other Names Used, Aliases (If Married Woman, Give Maiden Name)
Middle Name
4. Place of Birth (City, Province, Country)
5. Date of Birth (mm-dd-yyyy)
3. Current Home Address and Telephone Number
First Name
If married, information about spouse
d. Date of Birth (mm-dd-yyyy)
b. Address
a. Name (Last, First, MI.)
e. U.S. Residence Status, if any (U.S. Citizen, Legal Permanent Resident, Etc.)
f. Date of Marriage to You (mm-dd-yyyy)
c. Place of Birth
Married
e. Initial Entry into the United States as Lawful Permanent Resident
f. Last Entry into the United States as Lawful Permanent Resident
Date of Entry (mm-dd-yyyy)
Port of Entry
Date of Entry (mm-dd-yyyy) Port of Entry
a. DHS "A" Number b. Immigration Category
Date of Issue (mm-dd-yyyy) Place of Issue Date of Adjustment of Status
with DHS (IF ANY) (mm-dd-yyyy)
Place of Adjustment of
Status with DHS (IF ANY)
c. Previous Immigrant Visa d. Adjustment of Status
Reason
Date of Departure (mm-dd-yyyy)
Destination
Privacy Act and Paperwork Reduction Act Statements
This information asked for on this form is requested pursuant to Sections 101 and 222 of the Immigration and Nationality Act. The U.S. Department of State uses the facts you provide on this form to
determine your eligibility for returning resident status. Individuals who fail to submit this form or who do not provide all the requested information may be denied returning resident status. Upon your return to
the United States in immigrant status, the information collected will be protected from disclosure under the Privacy Act.
Widowed Divorced
