I-817, Application for Family Unity Benefits (United States)
This form is for members of the Family Unity Program to request initial benefits or an extension of benefits in the United States. The form provided here is simply a sample of what the actual Form I-817 looks like.
Department of Homeland Security
U.S. Citizenship and Immigration Services
I-817, Application for Family Unity Benefits
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FOR USCIS USE ONLY
Returned ___________________ Date
Resubmitted ___________________ Date
Reloc Sent ___________________ Date
Reloc Rec'd ___________________ Date
Receipt ___________________
____ Applicant Interviewed on ___________________
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Remarks
Action Block
____ Initial Application
____ Approved
____ Denied
Valid from: ___________________
to: ___________________
____ Request for Extension
____ Approved
____ Denied
Valid from: ___________________
to: ___________________
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To Be Completed By
Attorney or Representative, if any.
____ Fill in box if G-28 is attached to represent the petition.
ATTY State License # _______________________________
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Part 1. Information about you.
Family Name (Last Name) _______________________________
Given Name (First Name) _______________________________
Full Middle Name _______________________________
Date of Birth (mm/dd/yyyy) _______________________________
A # (if any) _______________________________
U.S. Social Security No. (if any) _______________________________
Country of Birth _______________________________
Country of Citizenship _______________________________
Gender ____ Male ____ Female
Home Address: Street Number and Name (include apartment number) _______________________________
City _______________________________
State _______________________________
Zip Code _______________________________
Mailing Address (If different from home address) _______________________________
C/O (In Care Of) _______________________________
City _______________________________
State _______________________________
Zip Code _______________________________
Daytime Phone Number (Area Code) _______________________________
Part 2. Basis for application.
1. I am applying for family unity benefits because: (check one box)
A. ____ I am the spouse of an alien who was legalized under section 245A of the INA and we have been married since at least May 5, 1988.
B. ____ I am the spouse of an alien who was legalized as a Special Agricultural Worker under section 210 of the INA and we have been married since at least December 1, 1988.
C. ____ As of May 5, 1988, I was the unmarried child under the age of 21 of an alien who was 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.
D. ____ As of December 1, 1988, I was the unmarried child under the age of 21 of an alien 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 alien or a naturalized U.S. citizen who was a legalized alien on or before December 1, 1988 and maintained such status until his or her naturalization.
E. ____ I am the spouse of a legalized alien who adjusted under section 202 of the Immigration Reform and Control Act of 1986 (Cuban/Haitian Adjustment) and we have been married since at least May 5, 1988.
F. ____ As of May 5, 1988, I was the unmarried child under the age of 21 of an alien who 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 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.
G. ____ I am the spouse 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.
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.
2. I am requesting: (check one box)
____ Initial family unity benefits under section 301 of IMMACT 90.
____ An extension of family unity benefits under section 301 of IMMACT 90.
____ Initial family unity benefits under section 1504 of P. L. 106-554, the LIFE Act Amendments.
3. I am claiming relationship to: (check one box)
____ A legalized alien under section 301 of IMMACT 90.
____ An alien who is eligible for and has filed for adjustment under section 1504 of P. L. 106-554, the LIFE Act Amendments.
Part 3. Additional information.
1. At the time of your last entry into the United States, you:
a. ____ were inspected and admitted
____ were inspected and paroled
____ entered without inspection
b. Date of last arrival (mm/dd/yyyy) _______________________________
I-94, Arrival Departure Document No. _______________________________
Current or most recent immigration status _______________________________
Date status expires (mm/dd/yyyy) _______________________________
Date continuous U.S. residence began (mm/dd/yyyy) _______________________________
2. Give the U.S. address where you lived on May 5, 1988 (sec. 245A/Cuban Haitian Adjustment) or December 1, 1988 (sec. 210/LIFE Act)
Street number and name (include apartment number) _______________________________
City _______________________________
State _______________________________
Zip Code _______________________________
3. Have you ever applied before for the Family Unity Program? ____ No ____ Yes (If "Yes," provide the following information)
Name under which you applied: _______________________________
City and state where application was filed _______________________________
Date filed (mm/dd/yyyy) _______________________________
USCIS (or former INS) action taken on case: ____ Approved ____ Denied
If separate applications for Family Unity benefits are being submitted at this time for other relatives, give the following information:
Family Name (Last Name) _______________________________
First Name _______________________________
Middle Name _______________________________
Relationship _______________________________
A# _______________________________
Family Name (Last Name) _______________________________
First Name _______________________________
Middle Name _______________________________
Relationship _______________________________
A# _______________________________
Family Name (Last Name) _______________________________
First Name _______________________________
Middle Name _______________________________
Relationship _______________________________
A# _______________________________
5. List all other names you have used (including maiden name)
6. List all absences from the United States since May 5, 1988 or December 1, 1988, as appropriate, or since the approval of you last Family Unity application (Form I-817), whichever date is later.
Date of Departure (mm/dd/yyyy) _______________________________
Date of Return (mm/dd/yyyy) _______________________________
Date of Departure (mm/dd/yyyy) _______________________________
Date of Return (mm/dd/yyyy) _______________________________
Date of Departure (mm/dd/yyyy) _______________________________
Date of Return (mm/dd/yyyy) _______________________________
NOTE; If you need more space to complete an answer, use a separate sheet(s) of paper. Write your name and A #, if you have one, at the top of each sheet and indicate the number of the item to which the answer refers.
7. List all residences in the United States since May 5, 1988 or December 1, 1988, as appropriate, or since the approval of your last Family Unity application (Form I-817), whichever date is later.
Street Number and Name (Include Apartment #) _______________________________
City _______________________________
State _______________________________
Zip Code _______________________________
Dates of Residence
From _______________________________
To Present
Street Number and Name (Include Apartment #) _______________________________
City _______________________________
State _______________________________
Zip Code _______________________________
Dates of Residence
From _______________________________
To _______________________________
Street Number and Name (Include Apartment #) _______________________________
City _______________________________
State _______________________________
Zip Code _______________________________
Dates of Residence
From _______________________________
To _______________________________
8. Do you have or have you ever had:
a. A communicable disease of public health significance (including chancroid, gonorrhea, granuloma inguinal, humanimmunodeficiency virus (HIV) infection, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, and active tuberculosis)? ____ Yes ____ No
b. A physical or mental disorder and behavior associated with the disorder which has posed or may pose a threat to the property, safety, or welfare of yourself or others? ____ Yes ____ No
Have you ever:
a. Knowingly committed a crime for which you have not been arrested? ____ Yes ____ No
b. Been convicted of a felony or three (3) or more misdemeanors in the United States? ____ Yes ____ No
c. Been convicted of two (2) or more offenses for which the aggregate sentences were five (5) or more years of confinement? ____ Yes ____ No
d. Been arrested, cited, charged, indicted, fined, or imprisoned for breaking or violating any law or ordinance? ____ Yes ____ No
e. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action? ____ Yes ____ No
f. Illicitly trafficked in any controlled substance or knowingly assisted, abetted or colluded with others in the illicit trafficking of any controlled substance? ____ Yes ____ No
g. Committed a criminal offense in the United States and asserted immunity from prosecution? ____ Yes ____ No
10. Have you, at any time within the past three (3) years, engaged in the non-medical use of any drug listed in section 202 of the Controlled Substances Act (including, but not limited to, sedative, hypnotic, or anxiolytic substances [tranquilizers], amphetamines, cannabinoids, cocaine, hallucinogens, opioids, phencyclidine [PCP], and related substances)? ____ Yes ____ No
11. Have you, at any time within the past two (2) years, engaged in the use of any psychoactive substance not listed in section 202 of the Controlled Substance Act (including, but not limited to, alcohol and inhalants) which resulted in behavior that has posed a threat to the property, safety or welfare of yourself or others or which behavior is likely to recur or to lead to other harmful behavior? ____ Yes ____ No
12. Have you ever committed an act of juvenile delinquency, which if committed by an adult would be classified as follows: (If you are a LIFE ACT applicant skip this question.) ____ Yes ____ No
a. A felony crime of violence that has as an element the use or attempted use of physical force against another? ____ Yes ____ No
b. A felony offense that by its nature involves a substantial risk that physical force against another may be used in the course of committing the offense? ____ Yes ____ No
13. Do you intend to engage solely, principally, or incidentally in prostitution in the United States, or are you now or have you within the past ten (10) years, engaged in, procured, or received income from prostitution? ____ Yes ____ No
14. Have you been or do you intend to be involved in any commercial vice? ____ Yes ____ No
15. Have you ever practiced or do you intend to practice polygamy? ____ Yes ____ No
16. Are you under a final order of civil penalty for violating section 274C of the Immigration and Nationality Act for use of fraudulent documents, or have you, by fraud or willful misrepresentation of a material fact, ever sought to procure, or procured, a visa, other documentation, entry into the United States, or any other immigration benefit? ____ Yes ____ No
17. Have you ever falsely represented yourself to be a citizen of the United States for any purpose or benefit under the Immigration and Nationality Act or any Federal or State law? ____ Yes ____ No
18. Are you a former citizen of the United States who renounced your U.S. citizenship for the purpose of avoiding taxation by the United States? ____ Yes ____ No
19. Have you ever been an F-1 nonimmigrant student who violated status by attending a public elementary or secondary school in violation of immigration law? ____ Yes ____ No
20. Have you ever failed or refused to attend or remain in attendance at a hearing to determine your admissibility to or deportability from the United States? ____ Yes ____ No
21. Have you ever been identified by USCIS (or former INS) as having obtained transportation to the United States without the consent of the owner, charterer, master or person in charge of the vessel or aircraft through concealment onboard such vessel or aircraft on which you arrived? ____ Yes ____ No
22. Have you been ordered deported, excluded, or removed from the United States? ____ Yes ____ No
23. Have you ever departed the United States after having been unlawfully present for 180 days but less than 365 days?
24. Have you ever departed the United States after having been unlawfully present for 365 days or longer? ____ Yes ____ No
25. Have you ever knowingly encouraged, induced, assisted, abetted, or aided, anyone to enter the United States in violation of the law? ____ Yes ____ No
26. Were you a guardian required to accompany an individual certified as helpless who was found to be inadmissible to the United States? ____ Yes ____ No
27. Have you detained, retained, or withheld the custody of a U.S. citizen child outside the United States from a person granted custody of such child by a U.S. court order? ____ Yes ____ No
28. Have you ever engaged in, conspired to engage in, or intended to engage solely, principally, or incidentally in:
a. Any activity to violate any U.S. law relating to espionage or sabotage? ____ Yes ____ No
b. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information? ____ Yes ____ No
c. Any other activity the purpose of which is in opposition to, or the control of, or overthrow of the government of the United States, by force, violence, or other unlawful means? ____ Yes ____ No
d. Any other unlawful activity? ____ Yes ____ No
29. Have you:
a. Ever engaged in, conspired to engage in, or intended to engage in a terrorist activity? ____ Yes ____ No
b. Ever incited terrorist activity with intent to cause death or serious bodily harm? ____ Yes ____ No
c. Ever been a representative of a terrorist organization or a member of an organization which you knew or should have known is a terrorist organization? ____ Yes ____ No
30. Have you ever engaged in or do you intend to engage in any activity in the United States that would have potentially serious adverse foreign policy consequences for the United States? ____ Yes ____ No
31. Have you:
a. Ever been, or are you now, a member of the Communist or other totalitarian party? ____ Yes ____ No
b. Ever engaged in genocide, or ordered, incited, assisted or otherwise participated in the persecution of any person because of race, religion, national origin, membership in a particular social group, or political opinion? ____ Yes ____ No
32. During the periods of March 23, 1933 to May 8, 1945, in association with either the Nazi Government of Germany or any organization or government associated or allied with the Nazi Government of Germany, did you ever order, incite, assist or otherwise participate in the persecution of any person because of race, religion, national origin, or political opinion? ____ Yes ____ No
33. Have you ever left the United States to avoid being drafted into the U.S. Armed Forces? ____ Yes ____ No
34. Have you received public assistance from any source, including the U.S. government or any state, county, city, or other municipality or, are you likely to request public assistance in the future? ____ Yes ____ No
35. Have you ever been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement and not yet complied with the requirement? ____ Yes ____ No
36. Have you ever voted in violation of any Federal, State, or local constitutional provision, statute, ordinance, or regulation? ____ Yes ____ No
NOTE: If you answered "Yes" to any of the above questions, provide a full explanation on a separate sheet(s) of paper.
Part 4. Information about your spouse or parent. Your spouse or parent must be either a legalized alien or an alien eligible for adjustment pursuant to the LIFE Act.
1. Provide the following information about the alien through whom you are claiming your eligibility.
Family Name (Last Name) _______________________________
Given Name (First Name) _______________________________
Full Middle Name _______________________________
Date of Birth (mm/dd/yyyy) _______________________________
A # (if any) _______________________________
U.S. Social Security No. (if any) _______________________________
Class of Admission _______________________________
Gender ____ Male ____ Female
Home Address: Street Number and Name (include apartment number) _______________________________
City _______________________________
State _______________________________
Zip Code _______________________________
Daytime Phone No. (Area Code) _______________________________
2. List all other names used, including maiden name. _______________________________
_______________________________
Part 5. Complete only if you are applying based on a marital relationship.
1. Provide the following information about you and your spouse.
Number of times you have been married. _______________________________
Number of times your spouse has been married _______________________________
2. Provide the following information about your current marriage.
Date of marriage (mm/dd/yyyy) _______________________________
Place of marriage (city, state or province and country) _______________________________
3. Type of ceremony. ____ Religious ____ Civil ____ None
4. We are: ____ Living together ____ Not living together
Part 6. Complete only if you are applying based on a child/parent relationship.
1. Please indicate how your parent is related to you.
____ Biological mother.
____ Biological father who was married to my mother when I was born.
____ Biological father who was not married to my mother when I was born.
____ Stepparent - based on marriage to my parent which occurred before my 18th birthday.
____ Adoptive parent and:
a. The adoption occurred before my 16th birthday. ____ Yes ____ No
b. My adoptive parent had legal custody of me for at least two years prior to May 5, 1988 or December 1, 1988, as appropriate. ____ Yes ____ No
c. I lived with my adoptive parent for at least two years prior to May 5, 1988 or December 1, 1988, as appropriate. ____ Yes ____ No
____ Parent based on circumstances not described above. (Explain in detail on a separate sheet of paper.)
2. Give the following information about your marital status.
____ Single ____ Married ____ Divorced ____ Widowed
3. Provide the following information if you are married, divorced or widowed.
Date of marriage (mm/dd/yyyy) _______________________________
Place of marriage (city, state or province and country) _______________________________
4. Type of ceremony.
____ Religious ____ Civil ____ None
5. We are:
____ Living together ____ Not living together
If divorced or widowed:
Date marriage ended (mm/dd/yyyy) _______________________________
Place marriage ended (city, state or province and country) _______________________________
Part 7. Signature. Read the information on penalties in the instructions before completing this section.
I certify, under penalty of perjury under the laws of the United States of America, that the information provided with this application is all true and correct. I certify also that I have not withheld any information that would affect the outcome of this application. I authorize the release of any information from my records that the U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit being sought.
Signature _______________________________
Date (mm/dd/yyyy) _______________________________
Part 8. Signature of person preparing form if other than above. (Sign below.)
I declare that I prepared this application at the request of the applicant and it is based on all information of which I have knowledge.
Attorney or Representative:
In the event of a Request for Evidence (RFE) may USCIS contact you by Fax or E-mail?
____ Yes ____ No
Preparer's Signature _______________________________
Date (mm/dd/yyyy) _______________________________
Preparer's Printed Name _______________________________
Preparer's Firm Name (if applicable) _______________________________
Preparer's Address _______________________________
Daytime Telephone Number (with area code) _______________________________
Fax Number (if any) _______________________________
E-Mail Address (if any) _______________________________