Form I-817 - Application For Family Unity Benefits Page 6
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128.a. Family Name
Part 4. Other Information (continued)
(Last Name)
8.b. Given Name
Provide the U.S. address where you lived on May 5, 1988 (INA
(First Name)
245Aor or Cuban Haitian Adjustment Act) or December 1,
1988 (INA section 210 or LIFE Act).
8.c.
Middle Name
4.a.
Street Number
►
A-
and Name
8.d.
A-Number (if any)
4.b.
Apt.
Ste.
Flr.
8.e. Relationship to Applicant
4.c.
City or Town
9.a. Family Name
4.d.
State
4.e. ZIP Code
(Last Name)
9.b. Given Name
If you are submitting separate applications for Family Unity
(First Name)
benefits at this time for other relatives, provide the following
9.c.
Middle Name
information about those other relatives.
►
NOTE: If you need more space to complete an answer in Item
A-
9.d.
A-Number (if any)
Numbers 5.a. - 24.f., use Part 9. Additional Information.
9.e. Relationship to Applicant
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
10.a. Family Name
(Last Name)
5.c.
Middle Name
10.b. Given Name
(First Name)
►
5.d.
A-Number (if any)
A-
10.c.
Middle Name
5.e. Relationship to Applicant
►
A-
10.d.
A-Number (if any)
10.e. Relationship to Applicant
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
List all absences from the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
6.c.
Middle Name
applies to you, or since the approval of your last Form I-817,
►
whichever date is later.
A-
6.d.
A-Number (if any)
11.a.
Departure Date (mm/dd/yyyy)
6.e. Relationship to Applicant
11.b.
Return Date (mm/dd/yyyy)
7.a. Family Name
(Last Name)
12.a.
Departure Date (mm/dd/yyyy)
7.b. Given Name
(First Name)
12.b.
Return Date (mm/dd/yyyy)
7.c.
Middle Name
13.a.
Departure Date (mm/dd/yyyy)
►
A-
7.d.
A-Number (if any)
13.b.
Return Date (mm/dd/yyyy)
7.e. Relationship to Applicant
14.a. Departure Date (mm/dd/yyyy)
14.b.
Return Date (mm/dd/yyyy)
Form I-817 12/23/16 N
Page 6 of 12
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