Form I-817 - Application For Family Units Benefits
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6OMB No. 1615-0005: Expires 02/28/2013
I-817, Application for
Department of Homeland Security
Family Unity Benefits
U.S. Citizenship and Immigration Services
START HERE - Type or print in black ink
For USCIS Use Only
Part 1. Information About You
Returned
Receipt
(Person requesting Family Unity Benefits)
Family Name (Last Name)
Given Name (First Name)
Full Middle Name
Date
Date
Date of Birth (mm/dd/yyyy)
U.S. Social Security No. (if any)
A-Number (if any)
Resubmitted
Country of Birth
Country of Citizenship
Gender
Date
Male
Female
Date
:
Home Address
Street Number and Name (include apartment number)
Reloc Sent
City
State
Zip Code
Date
Date
:
Mailing Address
(if different from home address)
Reloc Rec'd
Date
C/O: (In Care Of)
Date
City
State
Zip Code
Applicant
Interviewed
Daytime Phone Number (include area code)
on
Remarks
Part 2. Basis for Application
1.
I am applying for family unity benefits because: (Check one box)
I am the spouse of an alien who was legalized under section 245A of the INA, and we
A.
have been married since at least May 5, 1988.
Action Block
I am the spouse of an alien who was legalized as a Special Agricultural Worker under
B.
section 210 of the INA, and we have been married since at least December 1, 1988.
As of May 5, 1988, I was the unmarried child under the age of 21 of an alien who was
C.
legalized under section 245A of the INA. I am currently the child, son, or daughter of
the same parent. That parent is either a legalized alien or a naturalized U.S. citizen who
was a legalized alien on or before May 5, 1988, and maintained such status until his or
her naturalization.
As of December 1, 1988, I was the unmarried child under 21 years of age of an alien
D.
who was legalized as a Special Agricultural Worker under section 210 of the INA. I am
currently the child, son, or daughter of the same parent. That parent is either a legalized
Initial Application
alien or a naturalized U.S. citizen who was a legalized alien on or before December 1,
Approved
Denied
1988, and maintained such status until his or her naturalization.
Valid from:
to:
I am the spouse of a legalized alien who adjusted under section 202 of the Immigration
E.
Reform and Control Act of 1986 (Cuban/Haitian Adjustment), and we have been married
Request for Extension
since at least May 5, 1988.
Approved
Denied
As of May 5, 1988, I was the unmarried child under 21 years of age of an alien who
F.
Valid from:
to:
adjusted under section 202 of the Immigration Reform and Control Act of 1986
(Cuban/Haitian Adjustment). I am currently the child, son, or daughter of the same
To Be Completed by
parent. That parent is either a legalized alien or a naturalized U.S. citizen who was a
Attorney or Representative, if any
legalized alien on or before May 5, 1988, and maintained such status until his or her
Fill in box if G-28 is attached to
naturalization.
represent the applicant.
I am the spouse of an alien who is eligible for and has filed for adjustment under section
G.
1504 of P. L. 106-554, the LIFE Act Amendments. I entered the United States before
December 1, 1988, and was in the United States on that date.
ATTY State License #
H.
I am the unmarried child of an alien who is eligible for and has filed for adjustment
pursuant to section 1504 of P. L. 106-554, the LIFE Act Amendments. I entered the
United States before December 1, 1988, and was in the United States on that date.
Form I-817 (Rev. 02/28/12) Y
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