Form I-485 - Application To Register Permanent Residence Or Adjust Status Page 4
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18►
A-Number
A-
3.
Decision (for example, approved, refused, denied,
Part 2. Application Type or Filing Category
withdrawn)
(continued)
Information About Your Immigrant Category
4.
Date of Decision (mm/dd/yyyy)
If you are the principal applicant, provide the following
information.
Address History
3.
Receipt Number of Underlying Petition (if any)
Provide physical addresses for everywhere you have lived
during the last five years, whether inside or outside the United
States. Provide your current address first. If you need extra
4.
Priority Date from Underlying Petition (if any)
space to complete this section, use the space provided in
(mm/dd/yyyy)
Part 14. Additional Information.
If you are a derivative applicant (the spouse or unmarried
Physical Address 1 (current address)
child under 21 years of age of a principal applicant), provide the
5.a.
Street Number
following information for the principal applicant.
and Name
Principal Applicant's Name
5.b.
Apt.
Ste.
Flr.
5.a. Family Name
(Last Name)
5.c.
City or Town
5.b.
Given Name
(First Name)
5.d.
State
5.e.
ZIP Code
5.c.
Middle Name
5.f.
Province
6.
Principal Applicant's A-Number (if any)
5.g. Postal Code
►
A-
5.h.
Country
7.
Principal Applicant's Date of Birth
(mm/dd/yyyy)
Dates of Residence
8.
Receipt Number of Principal's Underlying Petition (if any)
►
6.a.
From (mm/dd/yyyy)
9.
Priority Date of Principal Applicant's Underlying Petition
6.b.
To (mm/dd/yyyy)
(if any) (mm/dd/yyyy)
Physical Address 2
7.a.
Street Number
Part 3. Additional Information About You
and Name
1.
Have you ever applied for an immigrant visa to obtain
7.b.
Apt.
Ste.
Flr.
permanent resident status at a U.S. Embassy or U.S.
Consulate abroad?
Yes
No
7.c.
City or Town
If you answered "Yes" to Item Number 1., complete
7.d.
State
7.e.
ZIP Code
Item Numbers 2.a. - 4. below. If you need extra space to
complete this section, use the space provided in Part 14.
7.f.
Province
Additional Information.
7.g. Postal Code
Location of U.S. Embassy or U.S. Consulate
7.h.
Country
2.a. City
Country
2.b.
Form I-485 06/26/17 N
Page 4 of 18
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