Application For Relief Under Former Section 212(C) Of The Immigration And Nationality Act (Ina) (Page 5 of 11) in pdf

Specific Instructions

Part 1. Information About You

Item Number 1. Your Full Name. Provide your full legal name as shown on your identity documents or legal change of

name document in the spaces provided.

Item Number 2. Other Names Used. Provide other names you have used since birth, including your maiden name, any

nicknames, and any names that appear in your documents. If you need extra space to complete this section, use the space

provided in Part 12. Additional Information.

Item Number 3. Date of Birth. Provide your date of birth in mm/dd/yyyy format in the space provided.

Item Number 4. Alien Registration Number (A-Number)(if any). An Alien Registration Number, otherwise known

as an “A-Number,” is typically issued to persons who apply for, or are granted, certain immigration benefits. If you

were issued an A-Number, type or print it into the spaces provided. If you do not have an A-Number, or if you cannot

remember it, leave this space blank.

Item Number 5. USCIS Online Account Number (if any). If you have previously filed an application, petition, or

request using the USCIS online filing system (previously called USCIS Electronic Immigration System (USCIS ELIS)),

provide the USCIS Online Account Number you were issued by the system. You can find your USCIS Online Account

Number by logging in to your account and going to the profile page. If you previously filed certain applications, petitions,

or requests on a paper form via a USCIS Lockbox facility, you may have received a USCIS Online Account Access Notice

issuing you a USCIS Online Account Number. If you received such a notice, your USCIS Online Account Number can be

found at the top of the notice. If you were issued a USCIS Online Account Number, enter it in the space provided. The

USCIS Online Account Number is not the same as an A-Number.

Item Number 6. Place of Birth. Provide the name of the city, town, or village, state or province, and country where you

were born.

Item Number 7. Country of Citizenship or Nationality. Provide the country where you are currently a citizen or

national. If you do not have citizenship in any country, indicate “stateless.”

Item Number 8. Mailing Address. Provide the address where you would like to receive written correspondence

regarding this application. Use a mailing address in the United States if you have one. If you do not have a U.S. mailing

address, provide your mailing address abroad.

Item Number 9. Physical Address. If the place where you live is different from your mailing address, provide the

address where you currently reside.

Item Number 10. Information About When and How You Became a Lawful Permanent Resident (LPR). Provide the

date when you became a Lawful Permanent Resident (LPR). Also select the box that shows how you obtained LPR status.

Select only one box.

Item Numbers 11. - 14. Passport and Travel Document Numbers. If you used a passport or travel document to travel

to the United States, enter either the passport or travel document information in the appropriate space on the application,

even if the passport or travel document is currently expired.

Item Number 15. Information About Your Departures From and Returns To the United States. List all dates you

departed from and returned to the United States since you became a LPR. Also provide a brief description of the means of

transportation that you used for travel, and the purpose of your trips.

If you have multiple trips from the United States, but do not remember the exact dates and/or details for the trip, you must

still list each trip separately and type or print “approximately” next to the information you provide for that trip.

Form I-191 Instructions 12/23/16 N

Page 5 of 11

Application For Relief Under Former Section 212(C) Of The Immigration And Nationality Act (Ina) Page 5