Form I-817 - Application For Family Unity Benefits
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12Application for Family Unity Benefits
USCIS
Form I-817
Department of Homeland Security
OMB No. 1615-0005
U.S. Citizenship and Immigration Services
Expires 10/31/2017
Fee Stamp
Action Block
For USCIS Use Only
Returned
Resubmitted
Received
Relocated
Sent
Remarks
Initial Application
Request for Extension
Approved
Denied
Approved
Denied
From
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From
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To
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To
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To be completed
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
by an attorney or
Form G-28 is
(if applicable)
USCIS Online Account Number (if any)
attached.
BIA-accredited
representative (if any).
►
START HERE - Type or print in black ink.
NOTE: You must reside and file Form I-817 while in the United States.
Part 1. Information About You (Person
Other Information
Requesting Family Unity Benefits)
5.
Date of Birth (mm/dd/yyyy)
1.
Alien Registration Number (A-Number) (if any)
►
6.
U.S. Social Security Number (if any)
A-
►
Your Full Name
7.
USCIS Online Account Number (if any)
►
2.a. Family Name
(Last Name)
8.
Gender
Male
Female
2.b. Given Name
(First Name)
9.
Country of Birth
2.c. Middle Name
10.
Country of Citizenship or Nationality
Other Names Used
Provide any other names you have used since birth, including
maiden names, and nicknames.
U.S. Mailing Address
3.a. Family Name
(Last Name)
11.a. In Care of Name
3.b. Given Name
(First Name)
11.b.
Street Number
3.c. Middle Name
and Name
11.c.
Apt.
Ste.
Flr.
4.a. Family Name
(Last Name)
11.d
City or Town
4.b. Given Name
(First Name)
11.e.
State
11.f.
ZIP Code
4.c. Middle Name
Form I-817 12/23/16 N
Page 1 of 12
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Parent category: Legal