Form I-817 - Application For Family Unity Benefits Page 7
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12Part 4. Other Information (continued)
Previous Residence 2
20.a.
Street Number
15.a.
Departure Date (mm/dd/yyyy)
and Name
15.b.
Return Date (mm/dd/yyyy)
20.b.
Apt.
Ste.
Flr.
20.c. City or Town
16.a.
Departure Date (mm/dd/yyyy)
20.d.
State
20.e. ZIP Code
16.b.
Return Date (mm/dd/yyyy)
20.f.
Dates of Residence (mm/dd/yyyy)
17.a.
Departure Date (mm/dd/yyyy)
From
To
17.b.
Return Date (mm/dd/yyyy)
Previous Residence 3
21.a.
Street Number
List all residences in the United States since May 5, 1988 or
and Name
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Family Unity
21.b.
Apt.
Ste.
Flr.
application (Form I-817), whichever date is later.
21.c. City or Town
Current Residence
21.d.
State
21.e. ZIP Code
18.a.
Street Number
and Name
21.f.
Dates of Residence (mm/dd/yyyy)
18.b.
Apt.
Ste.
Flr.
From
To
18.c. City or Town
Previous Residence 4
18.d.
State
18.e. ZIP Code
22.a.
Street Number
and Name
18.f.
Dates of Residence (mm/dd/yyyy)
From
To
Present
22.b.
Apt.
Ste.
Flr.
22.c. City or Town
Previous Residence 1
22.d.
State
22.e. ZIP Code
19.a.
Street Number
and Name
22.f.
Dates of Residence (mm/dd/yyyy)
19.b.
Apt.
Ste.
Flr.
From
To
19.c. City or Town
Previous Residence 5
19.d.
State
19.e. ZIP Code
23.a.
Street Number
and Name
19.f.
Dates of Residence (mm/dd/yyyy)
From
To
23.b.
Apt.
Ste.
Flr.
23.c. City or Town
23.d. State
23.e. ZIP Code
23.f.
Dates of Residence (mm/dd/yyyy)
From
To
Form I-817 12/23/16 N
Page 7 of 12
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Parent category: Legal