Form I-817 - Application For Family Unity Benefits Page 4
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12Part 3. Information About Your Relationship
19.d. Province
(continued)
19.e.
Country
Place of Prior Marriage
17.b.
City or Town
19.f. Date of Termination (mm/dd/yyyy)
Place of Termination
17.c. State
19.g. City or Town
17.d. Province
17.e.
Country
19.h.
State
19.i.
Province
17.f. Date of Termination (mm/dd/yyyy)
19.j. Country
Place of Termination
17.g.
City or Town
19.k. Reason for Termination
Divorce
Death
Annulment
Other (Provide an explanation if there are any other
17.h.
State
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
17.i.
Province
Part 9. Additional Information.)
17.j. Country
NOTE: If you were previously married, you must complete
Part 3. , Item Numbers 13. - 19.k. of this application; complete
17.k. Reason for Termination
all requested information about your prior marriages; and select
Divorce
Death
Annulment
the box in Item Number 20. indicating that it is complete.
Other (Provide an explanation if there are any other
I have completed Part 3., Item Numbers 13. - 19.k.,
20.
reasons for termination. If you need extra space to
information about my prior marriages (if any).
provide an explanation, use the space provided in
Part 9. Additional Information.)
Complete Only if You Are Applying Based on a
Child/Parent Relationship
Indicate how your parent is related to you (Select only one box)
Information About Your Spouse's Prior Spouse
21.a.
Biological mother
Provide the following information about your current spouse's
21.b.
prior marriages (if any).
Biological father who was married to my mother
when I was born
18.a. Family Name
(Last Name)
21.c.
Biological father who was not married to my mother
18.b. Given Name
when I was born
(First Name)
21.d.
Stepparent - based on marriage to my parent which
18.c. Middle Name
occurred before my 18th birthday
21.e.
19.a. Date of Marriage (if any) (mm/dd/yyyy)
Adoptive parent (select only one box):
A.
The adoption occurred before my 16th birthday.
Yes
No
Place of Marriage
B.
My adoptive parent had legal custody of me
19.b.
City or Town
on May 5, 1988 or December 1, 1988, (as
appropriate), and I resided with him or her for
two years prior to that date.
19.c. State
Yes
No
Form I-817 12/23/16 N
Page 4 of 12
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Parent category: Legal