Application To Replace Permanent Resident Card Page 2

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Part 3. Processing information (continued):

If you entered the U.S. with an Immigrant Visa, also complete the following:

Destination in U.S. at

Port of Entry where

time of Admission

Admitted to U.S.

Yes

Are you in removal/deportation or recission proceedings?

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?

Yes

If you answer yes to any of the above questions, explain in detail on a separate piece of paper.

Part 4. 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.

Signature

Date

Daytime Phone Number

Please Note: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you cannot be

found eligible for the requested document and this application may be denied.

Part 5. Signature of person preparing form, if other than above.

(Sign below)

I declare that I prepared this application at the request of the above person and it is based on all information of which I have knowledge.

Signature

Print Your Name

Date