Form I-687 - Application For Status As A Temporary Resident Under Section 245a Of The Immigration And Nationality Act

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Form I-687, Application for Status as a
Department of Homeland Security
Temporary Resident Under Section 245A of the INA
U.S. Citizenship and Immigration Services
Do not write in this block. For USCIS Use Only.
Action Block
Fee Stamp
Waiver of Inadmissibility Under
Applicant's A-Number
Section 212(a)___________________
Approved
Denied
Class of Admission
Place of Admission
Date of Adjustment
START HERE - Type or print in capital letters in black ink. (If you need more space, use a separate sheet of paper.)
1. I hereby apply for status as indicated by the block checked below:
A. Temporary Resident Status as an alien who illegally entered the U.S. prior to January 1, 1982.
B. Temporary Resident Status as an alien who entered the U.S. as a nonimmigrant prior to January 1, 1982, and whose
authorized stay expired before such date or whose unlawful status was known to the Government as of January 1, 1982.
2. Name
3. Date of Birth
Family Name (Last Name)
Given Name (First Name)
Middle Name
(mm/dd/yyyy)
4. Other A-Nos. and Names Used or Known By (including maiden name, if married)
5. Telephone Numbers (including area codes)
Home
Work
6. Home Address in the U.S.
U.S. Social Security No
In Care Of
Number and Street
Apt. No.
City
State
Zip Code
7. Mailing Address in the U.S. (if different from address in Number 6)
In Care Of
No. and Street Name
Apt. No.
City
State
Zip Code
8. Country of Citizenship
9. Place of Birth
City or Town
Country, Province, or State
Country
10. Marital Status
Now Married
Never Married
Separated
Divorced
Widowed
11. Gender
12. Race
Male
Other (specify below)
Asian or Pacific Islander
Black, not of Hispanic origin
Female
Hispanic
White, not of Hispanic origin
Form I-687 06/20/17 Y

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