H-1b Beneficiary Intake Form Page 4

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5. Have you ever been granted any other H status? .....................................................................................
Yes
No
If yes, please explain below:
6. Please list your prior periods of stay in H classification in the U.S. for the last six years. Include USCIS case numbers if
available. Provide copies of approval notices and I-94’s.
Period
Case #
Period
Case #
E. Family Information
I do not have dependents in the U.S.
I do have ____ dependents who require H-4 status.
My dependents do not require H-4 status.
1. Please list any dependent family members’ prior periods of stay in H status in the U.S. for the last six years. Include name,
relationship to you, and USCIS case numbers if available. Provide copies of approval notices and I-94s.
Name (LAST, first)
Relationship
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Case #
If dependents (spouse and/or children) are currently in the U.S., he/she must complete Form I-539 ( ) to petition for H-4
status or an extension of H-4 status. See the beneficiary checklist for additional information.
2. Do dependents (spouse and/or children) have any plans to travel abroad between now and the start date of this petition?
Yes
No
If yes, please list intended departure and return dates (mm/dd/yyyy):
to
I certify that the information above and documents submitted are true and correct. Photocopies of documents are exact copies of
unaltered original documents. I understand that any misrepresentation of information or document fraud will result in termination
of my employment at UConn.
_________________________________________ _______________________________________
____________________
Signature of Beneficiary
Print Name of Beneficiary
Date
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