Form I-485 - Application To Register Permanent Residence Or Adjust Status - Department Of Homeland Security Page 13
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A-Number
A-
63.c.
If your answer to Item Number 63.b. is "Yes," attach a
Part 8. General Eligibility and Inadmissibility
written statement explaining why you had reasonable cause.
Grounds (continued)
64.
Have you EVER submitted fraudulent or counterfeit
documentation to any U.S. Government official to obtain
Have you EVER ordered, incited, called for, committed, assisted,
or attempt to obtain any immigration benefit, including a
helped with, or otherwise participated in any of the following:
visa or entry into the United States?
Yes
No
58.a.
Acts involving torture or genocide?
Yes
No
65.
Have you EVER lied about, concealed, or misrepresented
58.b.
Killing any person?
Yes
No
any information on an application or petition to obtain a
visa, other documentation required for entry into the
58.c.
Intentionally and severely injuring any person?
United States, admission to the United States, or any other
Yes
No
kind of immigration benefit?
Yes
No
58.d.
Engaging in any kind of sexual contact or relations with
66.
Have you EVER falsely claimed to be a U.S. citizen (in
any person who did not consent or was unable to consent,
writing or any other way)?
Yes
No
or was being forced or threatened?
Yes
No
67.
Have you EVER been a stowaway on a vessel or aircraft
58.e. Limiting or denying any person's ability to exercise
arriving in the United States?
Yes
No
religious beliefs?
Yes
No
68.
Have you EVER knowingly encouraged, induced, assisted,
59.
Have you EVER recruited, enlisted, conscripted, or used
abetted, or aided any foreign national to enter or to try to
any person under 15 years of age to serve in or help an
enter the United States illegally (alien smuggling)?
armed force or group?
Yes
No
Yes
No
60.
Have you EVER used any person under 15 years of age
69.
Are you under a final order of civil penalty for violating
to take part in hostilities, or to help or provide services to
INA section 274C for use of fraudulent documents?
people in combat?
Yes
No
Yes
No
NOTE: If you answered “Yes” to any part of Item Numbers
52. - 60., explain what occurred, including the dates and
Removal, Unlawful Presence, or Illegal Reentry
location of the circumstances, in the space provided in Part 14.
After Previous Immigration Violations
Additional Information.
70.
Have you EVER been excluded, deported, or removed
from the United States or have you ever departed the
Public Assistance
United States on your own after having been ordered
61.
Have you received public assistance in the United States
excluded, deported, or removed from the United States?
from any source, including the U.S. Government or any
Yes
No
state, county, city, or municipality (other than emergency
medical treatment)?
71.
Have you EVER entered the United States without being
Yes
No
inspected and admitted or paroled?
Yes
No
62.
Are you likely to receive public assistance in the future in
the United States from any source, including the U.S.
Since April 1, 1997, have you been unlawfully present in the
Government or any state, county, city, or municipality
United States:
(other than emergency medical treatment)?
72.a. For more than 180 days but less than a year, and then
Yes
No
departed the United States?
Yes
No
72.b.
For one year or more and then departed the United States?
Illegal Entries and Other Immigration Violations
Yes
No
63.a.
Have you EVER failed or refused to attend or to remain
in attendance at any removal proceeding filed against you
NOTE: You were unlawfully present in the United States if
on or after April 1, 1997?
you entered the United States without being inspected and
Yes
No
admitted or inspected and paroled, or if you legally entered the
63.b. If your answer to Item Number 63.a. is "Yes," do you
United States but you stayed longer than permitted.
believe you had reasonable cause?
Yes
No
Form I-485 06/26/17 N
Page 13 of 18
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