8. Previous Immigration Record
First Name1. Family Name Middle Name
U.S. Department of State
EXPIRATION Date: 2/29/2020
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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.
2. Other Names Used, Aliases (If Married Woman, Give Maiden Name)
3. Current Home Address and Telephone Number
4. Place of Birth (City, Province, Country) 5. Date of Birth (mm-dd-yyyy)
6. Marital Status
Married Single (Never Married) Widowed Divorced
If married, information about spouse
a. Name (Last, First, MI)
b. Address
c. Place of Birth
d. Date of Birth (mm-dd-yyyy)
e. U.S. Residence Status, if any (U.S. Citizen, Legal Permanent Resident, Etc.)
f. Date of Marriage to You (mm-dd-yyyy)
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
a. DHS "A" Number b. Immigration Category
c. Previous Immigrant Visa d. Adjustment of Status
Date of Issue (mm-dd-yyyy)
Date of Adjustment of Status
with DHS (IF ANY) (mm-dd-yyyy)
Place of Adjustment of
Status with DHS (IF ANY)
Place of Issue
e. Initial Entry into the United 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
9. Most Recent Departure from the United States
Date of Departure (mm-dd-yyyy) Destination
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.
*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
documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB
control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov.
Privacy Act and Paperwork Reduction Act Statements
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
dd mmm yyyy
13. Have you been employed outside of the United States since your most recent departure?
10. What continuing ties have you maintained with the United States? What efforts have you made to avoid abandoning your permanent resident
status in the United States?
11. Reasons for not returning to the United States until time of this application.
12. List below all periods that you have lived outside of the United States for six months or longer since your initial entry into the United States as a
permanent resident.
If "Yes" complete the following:
Name of Employer Address From (mm-dd-yyyy) To (mm-dd-yyyy)
14. I wish to return to the United States on or about
Date (mm-dd-yyyy)
15. I swear or affirm that all statements which appear on this application are true and complete to the best of my knowledge and belief. I understand
that any false or misleading statement or willful concealment of a material fact may subject me to permanent exclusion from the United States. I
understand that if this application for special immigrant status is approved, I must apply for an immigrant visa within six months from the date of
Approved 101(a)(27)(A)
Concur Do NOT Concur
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Dates (mm-dd-yyyy)
From To
Date (mm-dd-yyyy)
Signature of Applicant
Type Name of Reviewing Officer
Date (mm-dd-yyyy)
Date (mm-dd-yyyy)
Signature of Reviewing Officer
Type Name of Consular Officer
Signature of Consular Officer
Yes No
dd mmm yyyy
click to sign
click to edit
dd mmm yyyy
click to sign
click to edit
click to sign
click to edit
dd mmm yyyy
dd mmm yyyy
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