Form I-90 - Application To Replace Permanent Resident Card - Department Of Homeland Security Page 4
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7Part 4. Accommodations for Individuals with
Applicant's Contact Information
Disabilities and/or Impairments (continued)
3.
Applicant's Daytime Telephone Number
1.b.
I am blind or have low vision and request the
following accommodation:
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
Applicant's Certification
1.c.
I have another type of disability and/or impairment
(Describe the nature of your disability and/or
Copies of any documents I have submitted are exact
impairment and the accommodation you are
photocopies of unaltered, original documents, and I understand
requesting):
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
any information from any of my records that USCIS may need
to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
Part 5. Applicant's Statement, Contact
administration and enforcement of U.S. immigration laws.
Information, Certification, and Signature
I understand that USCIS will require me to appear for an
NOTE: Read the Penalties section of the Form I-90
appointment to take my biometrics (fingerprints, photograph,
Instructions before completing this part.
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:
Applicant's Statement
1) I reviewed and provided or authorized all of the
NOTE: Select the box for either Item Number 1.a. or 1.b. If
information in my application;
applicable, select the box for Item Number 2.
2) I understood all of the information contained in, and
submitted with, my application; and
1.a.
I can read and understand English, and I have read
3) All of this information was complete, true, and correct
and understand every question and instruction on this
at the time of filing.
application and my answer to every question.
I certify, under penalty of perjury, that I provided or authorized
1.b.
The interpreter named in Part 6. read to me every
all of the information in my application, I understand all of the
question and instruction on this application and my
information contained in, and submitted with, my application,
answer to every question in
and that all of this information is complete, true, and correct.
,
Applicant's Signature
a language in which I am fluent and I understood
everything.
6.a.
Applicant's Signature
2.
At my request, the preparer named in Part 7.,
,
6.b.
Date of Signature
(mm/dd/yyyy)
prepared this application for me based only upon
information I provided or authorized.
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.
Form I-90 02/27/17 N
Page 4 of 7
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