Form I-360 - Petition For Amerasian, Widow(Er), Or Special Immigrant Page 3
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19Part 3. Information About the Person for Whom This Petition Is Being Filed
NOTE: On this petition, the "beneficiary" or "self-petitioner" means the person for whom this petition is being filed. If you provided
an alternate and/or safe mailing address above, you must also complete Part 3.
1.
Your Full Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
2.
Mailing Address
In Care Of Name (if any)
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Other Information
3.
Date of Birth (mm/dd/yyyy)
4.
Country of Birth
5.
U.S. Social Security Number (if any)
6.
A-Number (if any)
►
►
A-
7.
Marital Status
Single
Married
Divorced
Widowed
Complete Item Numbers 8. - 15. if this person is in the United States. If an item number is not applicable or the answer is "none," leave
the space blank. Provide information below for the passport or other document used at the time of last arrival to the United States.
8.
Date of Last Arrival (mm/dd/yyyy)
9.
Form I-94 Number or I-95 Crewman's Landing Permit
►
10.
Passport Number
11.
Travel Document Number
12.
Country of Issuance for Passport or Travel Document
13.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
14.
Current Nonimmigrant Status
15.
Date current status expired, or will expire, as shown on
Form I-94 or I-95 (mm/dd/yyyy)
Part 4. Processing Information
1.
If the person listed in Part 3. is outside the U.S., is ineligible to adjust status in the U.S., or does not wish to adjust status in the
U.S., provide the following information about the U.S. Consulate at which the person prefers to apply for an immigrant visa.
U.S. Consulate
A.
City or Town
B.
Country
Form I-360 12/23/16 N
Page 3 of 19
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