Form I-643 - Health And Human Services Statistical Data For Refugee/asylee Adjusting Status
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3OMB No: 1615-0070; Expires 10/31/2012
I-643, Health and Human Services Statistical
Department of Homeland Security
Data for Refugee/Asylee Adjusting Status
U.S. Citizenship and Immigration Services
At the bottom of the block enter your major occupation
What Is the Purpose of This Form?
before coming to the United States. If you did not work
before coming to the United States, enter "None."
Refugees and asylees, Cuban/Haitian Entrants under the Act
of November 1, 1996, and Amerasians under Public Law
Section 5
97-359 should submit Form I-643 when filing an application
Check the block or blocks that best describe your education
for adjustment of status.
before coming to the United States. Also, check the block
This form should be fully completed by a refugee or asylee
or blocks that best describe how and where you have
who is 16 years of age or older. Representatives of applicants
learned English.
younger than 16 years of age should only complete Blocks 1
Section 6
and 2.
If you have had any training or education in the United
Although the information requested on Form I-643 will not
States, check the block or blocks that best describe your
affect the adjudication of the adjustment application, your
training and enter your major course of study. If you have
application will not be considered as completely filed unless
not had any training in the United States, enter "None."
you submit this form. The data collected on this form will be
Section 7
used by U.S. Department of Health and Human Services to
Check the appropriate block that best describes your ability
compile and analyze statistics relating to refugees and asylees.
to speak, read, and write English.
Form I-643 will not be retained by U.S. Citizenship and
Immigration Services (USCIS).
Section 8
Check as many types of public assistance that you have
How to Complete Form I-643
received or someone has received on your behalf. Indicate
the month and year the assistance started and stopped. If
you are still receiving assistance, write "Present" in the
NOTE: Applicant - Print or type in blue or black ink
block headed "To (mm/yyyy)," noting month/year.
Section 1
Enter your name, the date on which you are completing
this form, and your Alien Registration Number on the first
Paperwork Reduction Act
line. On the second line, enter your country of birth and
your country of citizenship. On the third line, enter your
An agency may not conduct or sponsor an information
native language, your date of birth, and your telephone
collection and a person is not required to respond to a
number. Enter your current address on the fourth line.
collection of information unless it displays a currently valid
OMB control number. The public reporting burden for this
Section 2
collection of information is estimated at 55 minutes per
Fill in your three most recent cities and states of residence
response, including the time for reviewing instructions and
in the United States in order, starting with your current
completing and reviewing the collection of information.
place of residence. If you have not lived in three different
Send comments regarding this burden estimate or any other
cities since you entered the United States, write "None" on
aspect of this collection of information, including
as many lines as appropriate.
suggestions for reducing this burden, to: U.S. Citizenship
Section 3
and Immigration Services, Regulatory Products Division,
Show the total number of people living in your household
Office of the Executive Secretariat, 20 Massachusetts
and the number currently employed. Fill in the first line
Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC
for yourself, then list any other persons who live in your
20529-2210. OMB No. 1615-0070. Do not mail your
household. If more than five persons live with you, attach
application to this address.
a separate page listing the others and provide the
information requested.
Section 4
Enter the information about all jobs you have held since
coming to the United States, starting with your current or
most recent job. Under "Job Title" write the term that best
describes the work you do, such as "machine operator,"
"nurse," or "chemist." If you have not worked at all since
coming to the United States, write "None."
Form I-643 Instructions (Rev. 10/08/10) Y
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