Form I-485 - Supplement A - Adjustment Of Status Under Section 245(I) Page 2
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41.i.
You are seeking employment-based adjustment of
Part 2. Eligibility (continued)
status and you are not maintaining a lawful
Information on Principal Beneficiary of Petition or Application
nonimmigrant status on the date of filing your
application for adjustment of status.
3.a. Family Name
(Last Name)
1.j.
You have ever violated the terms of your
3.b.
Given Name
nonimmigrant status.
(First Name)
3.c.
Middle Name
Part 4. Applicant's Statement, Contact
4.
Principal Applicant's A-Number (if any)
Information, Declaration, Certification, and
►
A-
Signature
Immigrant Category
NOTE: Read the Penalties section of the Supplement A
Instructions before completing this part. You must file
5.
Type or print the family-based, employment-based,
Supplement A while in the United States.
special immigrant, or Diversity Visa immigrant category
you selected on Form I-485, Part 2. Application Type or
Applicant's Statement
Filing Category, Item Numbers 1.a. - 1.g.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
Part 3. Bars to Adjustment
and understand every question and instruction on this
You are applying to adjust under INA section 245(i) because
supplement and my answer to every question.
one or more of the following bars to adjustment apply to you
The interpreter named in Part 5. read to me every
1.b.
(Select all applicable boxes):
question and instruction on this supplement and my
You last entered the United States without being
answer to every question in
1.a.
admitted or paroled after inspection by an
,
immigration officer.
a language in which I am fluent, and I understood
1.b.
You last entered the United States as a nonimmigrant
everything.
crewman.
2.
At my request, the preparer named in Part 6.,
1.c.
You are now employed or have ever been employed
,
in the United States without authorization.
prepared this supplement for me based only upon
1.d.
You are not in lawful immigration status on the date
information I provided or authorized.
of filing your application for adjustment of status.
Applicant's Contact Information
1.e.
You have ever failed to continuously maintain a
lawful status since entry into the United States, unless
3.
Applicant's Daytime Telephone Number
your failure to maintain status was through no fault of
your own or for technical reasons.
4.
Applicant's Mobile Telephone Number (if any)
1.f.
You were last admitted to the United States in transit
without a visa.
1.g.
You were last admitted to the United States as a
5.
Applicant's Email Address (if any)
nonimmigrant visitor without a visa under the Guam
and Commonwealth of the Northern Mariana Islands
Visa Waiver Program, and you are not a Canadian
citizen.
1.h.
You were last admitted to the United States as a
nonimmigrant visitor without a visa under the Visa
Waiver Program (See
travel.state.gov/content/visas/
english/visit/visa-waiver-program.html).
Page 2 of 4
Form I-485 Supplement A 06/26/17 N
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