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I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status (United States)

This form is adjusts the status of a refugee/asylee of the United States. The form provided here is simply a sample of what the actual Form I-643 looks like.

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status

Please Print or Type in Black Ink. - See Instructions on Reverse Side.

1. Name

Last (Family) ____________________________

First (Given) ____________________________

Middle ____________________________

Country of Birth: ____________________________

Country of Citizenship: ____________________________

Today's Date: (mm/dd/yyyy) ____________________________

Alien Registration Number: A-____________________________

Country of Birth: ____________________________

Native Language: ____________________________

Date of Birth (mm/dd/yyyy) ____________________________

Telephone Number (with area code) ____________________________

Current Address:

____________________________ (Number, Street and Apartment No.)

____________________________ (City)

____________________________ (State)

____________________________ (Zip Code)

2. My three (3) most recent cities of residence in the United States have been: (List most recent first)

City or Town ____________________________

State ____________________________

From (mm/dd/yyyy) ____________________________

To (mm/dd/yyyy) Present

City or Town ____________________________

State ____________________________

From (mm/dd/yyyy) ____________________________

To (mm/dd/yyyy) ____________________________

3. There are _________ members of my household, _______________ of whom are employed. (Please use another sheet(s) if needed)

Name (Self) ____________________________

Relationship to Me (Self) ____________________________

Gender M/F ____________________________

Date of Birth (mm/dd/yyyy) ____________________________

Country of Birth ____________________________

Alien Number ____________________________

Currently Employed? ____ Yes ____ No

Attending School? ____ Yes ____ No


Name ____________________________

Relationship to Me ____________________________

Gender M/F ____________________________

Date of Birth (mm/dd/yyyy) ____________________________

Country of Birth ____________________________

Alien Number ____________________________

Currently Employed? ____ Yes ____ No

Attending School? ____ Yes ____ No


Name ____________________________

Relationship to Me ____________________________

Gender M/F ____________________________

Date of Birth (mm/dd/yyyy) ____________________________

Country of Birth ____________________________

Alien Number ____________________________

Currently Employed? ____ Yes ____ No

Attending School? ____ Yes ____ No

4. My employment since entering the United States has been: (List most recent first)

Company Name ____________________________

Location City, State ____________________________

From (mm/dd/yyyy) ____________________________

To (mm/dd/yyyy) ____________________________

Job Title ____________________________

Wage per Hour ____________________________

____ Part Time ____ Full Time (Check One)


Company Name ____________________________

Location City, State ____________________________

From (mm/dd/yyyy) ____________________________

To (mm/dd/yyyy) ____________________________

Job Title ____________________________

Wage per Hour ____________________________

____ Part Time ____ Full Time (Check One)

My major occupation or profession before coming to the United States was: ____________________________

5. My education before coming to the United States was: (Check all that apply)

____ Grades 1-8
____ Some high school
____ High school diploma
____ Technical school
____ Technical school certificate
____ Some university
____ University diploma
____ Graduate studies
____ Professional training
____ Graduate degree

My knowledge of English was acquired by: (Check all that apply)

____ Training in the U.S.
____ Use in the U.S.
____ Training in another country
____ Use in another country
____ Training in refugee camp
____ Other (Please explain): ____________________________

6. I have had the following training or education in the U.S. (Check all that apply)

Type of Training/Education

____ High school

Course of Study ____________________________

____ Still Attending ____ Completed


____ College

Course of Study ____________________________

____ Still Attending ____ Completed


____ Technical/Vocational

Course of Study ____________________________

____ Still Attending ____ Completed


____ Other (specify): ____________________________

Course of Study ____________________________

____ Still Attending ____ Completed

7. My English ability is: (Check one)

____ None
____ Fair
____ Good
____ A few words

8. Since in the United States, check as many types of public assistance that you have received or someone has received on your behalf:

Public Assistance:

____ Cash assistance (Welfare)

From (mm/yyyy) ____________________________

To (mm/yyyy) ____________________________

____ Food Stamps

From (mm/yyyy) ____________________________

To (mm/yyyy) ____________________________

____ SSI

From (mm/yyyy) ____________________________

To (mm/yyyy) ____________________________

____ Medical assistance

From (mm/yyyy) ____________________________

To (mm/yyyy) ____________________________

____ Other (specify): ____________________________

From (mm/yyyy) ____________________________

To (mm/yyyy) ____________________________


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INSTRUCTIONS FOR FILLING OUT THIS FORM
-----------------------------

Purpose of This Form. Refugees and asylees should submit this Form I-643 when filing an application for adjustment of status. This form should be fully completed by a refugee or asylee, age 16 years or older. Representatives of applicants younger than 16 should only complete Blocks 1 and 2.

Although the information requested on Form I-643 will not affect the adjudication of the adjustment application, your application will not be considered as completely filed unless you submit this form. The data collected on this form will be used by the U.S. Department of Health and Human Services to compile and analyze statistics relating to refugees and asylees. The form will not be retained by the U.S. Citizenship and Immigration Services (CIS). NOTE: The CIS is comprised of the offices of the former Immigration and Naturalization Service (INS).

Reporting Burden. An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. This collection of information is estimated to average from 10 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Bureau of Citizenship and Immigration Services, 425 I Street, N.W., Room 4034, Washington, DC 20529; OMB No. 1615-0070. Do not mail your completed application to this address.

Privacy Act Notice. Our legal right to ask for this information is in 8 U.S.C. 1184. All the information provided on this form, including addresses, are protected by the Privacy Act and the Freedom of Information Act. This information will not be released in any form whatsoever to a third party, other than another government agency, who requests it without a court order or without your written consent, or in the case of a child, the written consent of the parent or legal guardian who filed the form on the child's behalf.

Block 1: Enter your name, the date on which you are completing this form and your Alien Registration Number on the first line. On the second line, enter your country of birth and your country of citizenship. On the third line, enter your native language, your date of birth and your telephone number. Enter your current address on the fourth line.

Block 2: Fill in your three (3) most recent cities and states of residence in the United States in order, starting with your current place of residence. If you have not lived in three (3) different cities since you entered the United States, write "none" on as many lines as appropriate.

Block 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." At the bottom of the block enter your major occupation before coming to the United States. If you did not work before coming to the United States, enter "none."

Block 5: Check the block or blocks that best describe your education before coming to the United States. Also, check the block or blocks that best describe how and where you have learned English.

Block 6: If you have had any training or education in the United States, check the block or blocks that best describe your training and enter your major course of study. If you have not had any training in the United States, enter "none."

Block 7: Check the block that best describes your ability to use English.

Block 8: Check as many types of public assistance as you have 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 block headed "To (mm/yyyy)," noting month/year.


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Instructions to CIS Officer

After this form has been completed, forward it directly to the address as shown below: (If you are mailing a small number of forms, they may be folded so that the address shows through a #20 window envelope).

Data Unit, Office of Refugee Resettlement
Department Of Health And Human Services
370 L'Enfant Promenade S.W., (6th Floor)
Washington, D.C. 20447

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