Fillable Printable Application to Replace Permanent Residence Card - U.S. Homeland Security
Fillable Printable Application to Replace Permanent Residence Card - U.S. Homeland Security
Application to Replace Permanent Residence Card - U.S. Homeland Security
Form I-90 06/30/15 Y
For
USCIS
Use
Only
Application to Replace Permanent Resident Card
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-90
OMB No. 1615-0082
Expires 10/31/2017
START HERE - Type or print in black ink.►
Part 1. Information About You
Alien Registration Number (A-Number)
Your Full Name
NOTE: Your card will be issued in this name.
3.a.Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.
4.
Middle Name
Has your name legally changed since the issuance of your
Permanent Resident Card?
Yes (Proceed to Item Numbers5.a. - 5.c.)
No (Proceed to Item Numbers6.a. - 6.i.)
N/A - I never received my previous card.
(Proceed to Item Numbers6.a. - 6.i.)
1.
Street Number
and Name
Mailing Address
6.a.
InCare Of Name
6.b.
6.c.
Apt.Flr.Ste.
6.d. City or Town
6.h.
Postal Code
6.i.Country
6.e.
State
6.f.
ZIP Code
Class of Admission
Applicant Interviewed
Action BlockReceipt
Date:
Remarks
Provide your name exactly as it is printed on your current
Permanent Resident Card.
NOTE: Attach all evidence of your legal name change with
this application.
5.a.Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c.
Middle Name
USCIS ELIS Account Number (if any)2.
►
6.g.
Province
Page 1 of 8
A-
Form I-90 06/30/15 Y
9.
10.
Part 1. Information About You (continued)
8.
Date of Birth (mm/dd/yyyy)►
City/Town/Village
ofBirth
Country of Birth
►
14.
13.
Class of Admission
Date of Admission
(mm/dd/yyyy)►
U.S. Social Security Number (if any)
15.
2.e.
My name or other biographic information has been
legally changed since issuance of my existing card.
2.f.
My existing card has already expired or will expire
within six months.
2.g1.
I have reached my 14th birthday and am registering
as required. My existing card will expire AFTER my
16th birthday. (See NOTE below for additional
information.)
I have reached my 14th birthday and am registering
as required. My existing card will expire BEFORE
my 16th birthday. (See NOTE below for additional
information.)
2.g2.
2.d.
My existing card has incorrect data because of
Department of Homeland Security (DHS) error.
(Attach your existing card with incorrect data along
with this application.)
Mother's Name
Father's Name
11.
Given Name
(First Name)
12.
Given Name
(First Name)
Reason for Application (Select only one box)
Section A. (To be used only by a lawful permanent resident or
a permanent resident in commuter status.)
2.a.
My previous card has been lost, stolen, or destroyed.
2.b.
My previous card was issued but never received.
2.c.
My existing card has been mutilated.
Additional Information
16.
GenderMaleFemale
Part 2. Application Type
NOTE: If your conditional permanent resident status (for
example: CR1, CR2, CF1, CF2) is expiring within the next 90
days, then do not file this application. (See the What is the
Purpose of This Application section of the Form I-90
Instructions for further information.)
My status is (Select only one box):
1.a.
Lawful Permanent Resident(Proceed to Section A.)
1.b.
Permanent Resident - In Commuter Status
(Proceed to Section A.)
1.c.
Conditional Permanent Resident
(Proceed to Section B.)
Physical Address
7.a. Street Number
and Name
7.c. City or Town
7.d.
State
7.e.
ZIP Code
7.b.
Apt.Flr.Ste.
Provide this information only if different than mailing address.
Country 7.h.
Postal Code
7.g.
Province
7.f.
NOTE: If you are filing this application before your
14th birthday, or more than 30 days after your 14th
birthday, you must select reason 2.j. However, if
your card has expired, you must select reason 2.f.
Page 2 of 8
Form I-90 06/30/15 Y
1.
2.
Location where you applied for an immigrant visa or
adjustment of status:
Location where your immigrant visa was issued or USCIS
office where you were granted adjustment of status:
4.
5.
Have you ever been in exclusion, deportation, or removal
proceedings or ordered removed from the United States?
NoYes
Since you were granted permanent residence, have you
ever filed Form I-407, Abandonment by Alien of Status as
Lawful Permanent Resident, or otherwise been determined
to have abandoned your status?
NoYes
NOTE: If you answered "Yes" to Item Numbers 4. or 5.
above, provide a detailed explanation in the space provided in
Part 8. Additional Information.
6.
7.
Height
9.Weight
FeetInches
8.
Pounds
3.b.
My previous card was issued but never received.
3.c.My existing card has been mutilated.
3.d.
My existing card has incorrect data because of DHS
error. (Attach your existing permanent resident card
with incorrect data along with this application.)
3.e.
My name or other biographic information has legally
changed since the issuance of my existing card.
Part 3. Processing Information
Part 2. Application Type (continued)
Section B. (To be usedonlyby a conditional permanent resident.)
3.a.My previous card has been lost, stolen, or destroyed.
Port-of-Entry where admitted to the United States:3.a1.
2.j.
I have a prior edition of the Alien Registration Card,
or I am applying to replace my current Permanent
Resident Card for a reason that is not specified above.
2.h1.1.
2.h2.
I am a commuter who is taking up actual residence in
the United States.
2.i.
I have been automatically converted to lawful
permanent resident status.
My Port-of-Entry (POE) into the United States will be:
Biographic Information
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select onlyone box)
Race (Select allapplicable boxes)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
2.h1.
I am a permanent resident who is taking up commuter
status.
White
Asian
Black or African American
BlackBrown
Maroon
Pink
HazelGreen
Blue
10.
Eye Color (Select only one box)
Unknown/Other
Gray
Page 3 of 8
Complete Item Numbers3.a. and 3.a1. if you entered the
United States with an immigrant visa. (If you were granted
adjustment of status, proceed to Item Number 4.)
City or Town and State
City or Town and State
3.a.Destination in the United States at time of admission
White
Hair Color (Select only one box) 11.
Black
BrownRed
Unknown/Other
Sandy
Gray
BlondBald (No hair)
Form I-90 06/30/15 Y
1.b.
I am blind or have low vision and request the
following accommodation:
Part 4. Accommodations for Individuals with
Disabilities and/or Impairments (Read the
information in the Form I-90 Instructions before
completing this part.)
1.Are you requesting an accommodation because of your
disabilities and/or impairments?
NoYes
1.a.
I am deaf or hard of hearing and request the
following accommodation (If you are requesting a
sign-language interpreter, indicate for which
language (for example, American Sign Language)):
If you answered "Yes," select any applicable boxes:
Page 4 of 8
1.c.
I have another type of disability and/or impairment
(Describe the nature of your disability and/or
impairment and the accommodation you are
requesting):
Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and have read and
understand every question and instruction on this
application, as well as my answer to every question.
I have read and understand the Acknowledgement of
Appointment at USCIS Application Support
Center.
NOTE: Read the information on penalties in the Form I-90
Instructions before completing this part. You must file Form
I-90 while in the United States.
Applicant's Statement
1.b.
The interpreter named in Part 6. has read to me every
question and instruction on this application, as well as
my answer to every question, in
a language in which I am fluent. I understand every
question and instruction on this application as
translated to me by my interpreter, and have provided
complete, true, and correct responses in the language
indicated above. The interpreter named Part 6. has
also read the Acknowledgement of Appointment at
USCIS Application Support Center to me, in the
language in which I am fluent, and I understand this
Application Support Center (ASC)
Acknowledgement as read to me by my interpreter.
,
2.I have requested the services of and consented to
isis not an attorney or accredited
representative, preparing this application for me.
This person who assisted me in preparing my
application has reviewed the Acknowledgement of
Appointment at USCIS Application Support
Center with me, and I understand the ASC
Acknowledgement.
,
NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
who
Form I-90 06/30/15 Y
Applicant's Certification
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit I seek.
►(mm/dd/yyyy)Date of Signature:6.b.
Applicant's Signature6.a.
I certify, under penalty of perjury, that the information in my
application and any document submitted with my application
were provided by me and are complete, true, and correct.
Applicant's Contact Information
Applicant's Daytime Telephone Number3.
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration of U.S. immigration laws.
Applicant's Signature
Page 5 of 8
Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature (continued)
Acknowledgement of Appointment at USCIS
Application Support Center
I, ,
understand that the purpose of a USCIS ASC appointment is
for me to provide fingerprints, photograph, and/or signature
and to re-affirm that all of the information in my application
is complete, true, and correct and was provided by me. I
understand that I will sign my name to the following
declaration which USCIS will display to me at the time I
provide my fingerprints, photograph, and/or signature during
my ASC appointment:
I also understand that when I sign my name, provide my
fingerprints, and am photographed at the USCIS ASC, I will be
re-affirming that I willingly submit this application; I have
reviewed the contents of this application; all of the information
in my application and all supporting documents submitted with
my application were provided by me and are complete, true, and
correct; and if I was assisted in completing this application, the
person assisting me also reviewed this Acknowledgement of
Appointment at USCIS Application Support Center with me.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Provide the following information concerning the interpreter.
Part 6. Interpreter's Contact Information,
Certification, and Signature
By signing here, I declare under penalty of perjury that I
have reviewed and understand my application, petition, or
request as identified by the receipt number displayed on the
screen above, and all supporting documents, applications,
petitions, or requests filed with my application, petition, or
request that I (or my attorney or accredited representative)
filed with USCIS, and that all of the information in these
materials is complete, true, and correct.
Form I-90 06/30/15 Y
Part 6. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Contact Information
4.Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)5.
Page 6 of 8
3.h.
Interpreter's Mailing Address
3.c.City or Town
3.d.State3.e.ZIP Code
3.f.Province
Street Number
and Name
3.a.
Country
3.b.Apt.Flr.Ste.
3.g.Postal Code
►(mm/dd/yyyy)Date of Signature6.b.
Interpreter's Signature6.a.
The applicant has informed me that he or she understands every
instruction and question on the application, as well as the answer
to every question, and the applicant verified the accuracy of
every answer; and
The applicant has also informed me that he or she understands
the ASC Acknowledgement and that by appearing for a USCIS
ASC biometric services appointment and providing his or her
fingerprints, photographs, and/or signature, he or she is
re-affirming that the contents of this application and all
supporting documentation are complete, true, and correct.
Interpreter's Signature
Part 7. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Application, If Other Than the
Applicant
Preparer's Full Name
1.a.
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
1.b.
Interpreter's Certification
I certify that:
is the same language provided in Part 5., Item Number 1.b.;
I am fluent in English and which
I have read to this applicant every question and instruction on
this application, as well as the answer to every question, in the
language provided in Part 5., in ItemNumber 1.b.; and
I have read the Acknowledgement of Appointment at USCIS
Application Support Center to the applicant in the same
language provided in Part 5., in Item Number 1.b.
Provide the following information concerning the preparer.
Preparer's Business or Organization Name (if any)2.
Form I-90 06/30/15 Y
Preparer's Mailing Address
3.h.
3.c.City or Town
3.d.State3.e.ZIP Code
3.f.
Province
Street Number
and Name
3.a.
Country
3.b.Apt.Flr.Ste.
3.g.Postal Code
Page 7 of 8
Part 7. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Application, If Other Than the
Applicant (continued)
Preparer's Contact Information
4.Preparer's Daytime Telephone Number
6.Preparer's Email Address (if any)
5.Preparer's Fax Number (if any)
NOTE: If you do not completely fill out this application or fail
to submit required documents listed in the instructions, your
application may be denied.
8.a. Preparer's Signature
8.b.Date of Signature(mm/dd/yyyy)►
Preparer's Certification
By my signature, I certify, swear or affirm, under penalty of
perjury, that I prepared this application on behalf of, at the
request of, and with the express consent of, the applicant. I
completed this application based only on responses the
applicant provided to me. After completing the application, I
reviewed it and all of the applicant's responses with the
applicant, who agreed with every answer on the application. If
the applicant supplied additional information concerning a
question on the application, I recorded it on the application. I
have also read the Acknowledgement of Appointment at
USCIS Application Support Center to the applicant and the
applicant has informed me that he or she understands the ASC
Acknowledgement.
I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.
7.a.
7.b.
preparation of this application.
I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend beyond the
Preparer's Statement
Preparer's Signature
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this application, you must submit a
completed Form G-28, Notice of Attorney or
Accredited Representative, with this application.
Form I-90 06/30/15 Y
3.d.
5.a.
Page Number5.b.Part Number5.c.Item Number
5.d.
4.d.
Part 8. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Include your name and A-Number (if any) at the
top of each sheet; indicate the Page Number, Part Number,
and Item Number to which your answer refers; and sign and
date each sheet.
Your Full Name
1.a.Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.Middle Name
2.A-Number (if any)
3.a.Page Number3.b.Part Number3.c.Item Number
4.a.
Page Number4.b.Part Number4.c.Item Number
Page 8 of 8
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