The beneficiary will not apply for adjustment of status in
Part 4. Information About Beneficiary
the United States, but he or she will apply for an immigrant
(continued)
visa abroad at the U.S. Embassy or U.S. Consulate in:
If the beneficiary's native written language does not use
62.a.
City or Town
Bisho
Roman letters, type or print his or her name and foreign
address in their native written language.
62.b.
Province
Eastern Cape
57.a.
Family Name
N/A
(Last Name)
62.c.
Country
57.b.
Given Name
N/A
South Africa
(First Name)
57.c. Middle Name
N/A
NOTE: Choosing a U.S. Embassy or U.S. Consulate outside
the country of the beneficiary's last residence does not
58.a.
Street Number
N/A
guarantee that it will accept the beneficiary's case for
and Name
processing. In these situations, the designated U.S. Embassy or
58.b.
Apt.
Ste.
Flr.
N/A
U.S. Consulate has discretion over whether or not to accept the
beneficiary's case.
58.c. City or Town
N/A
Part 5. Other Information
58.d.
Province
N/A
1.
Have you EVER previously filed a petition for this
58.e. Postal Code
N/A
beneficiary or any other alien?
Yes
No
58.f. Country
If you answered "Yes," provide the name, place, date of filing,
N/A
and the result.
2.a.
Family Name
N/A
If filing for your spouse, provide the last address at which
(Last Name)
you physically lived together. If you never lived together,
2.b.
Given Name
N/A
type or print, "Never lived together" in Item Number 59.a.
(First Name)
59.a.
Street Number
2.c.
Middle Name
N/A
N/A
and Name
59.b.
Apt.
Ste.
Flr.
3.a. City or Town
N/A
N/A
59.c. City or Town
3.b. State
N/A
N/A
59.d. State
59.e. ZIP Code
4.
Date Filed (mm/dd/yyyy)
N/A
N/A
N/A
5.
Result (for example, approved, denied, withdrawn)
59.f.
Province
N/A
N/A
59.g. Postal Code
N/A
If you are also submitting separate petitions for other relatives,
59.h.
Country
provide the names of and your relationship to each relative.
N/A
Relative 1
6.a.
Family Name
60.a.
Date From (mm/dd/yyyy)
N/A
N/A
(Last Name)
6.b.
Given Name
60.b.
Date To (mm/dd/yyyy)
N/A
N/A
(First Name)
6.c.
Middle Name
N/A
The beneficiary is in the United States and will apply for
adjustment of status to that of a lawful permanent resident
7.
Relationship
N/A
at the U.S. Citizenship and Immigration Services (USCIS)
office in:
61.a.
City or Town
N/A
61.b.
State
N/A
Form I-130 02/27/17 N
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