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Fillable Printable Form I-687

Fillable Printable Form I-687

Form I-687

Form I-687

Waiver of Inadmissibility Under
Section 212(a)___________________
Department of Homeland Security
U.S.Citizenship and Immigration Services
Do not write in this block. For USCIS Use Only.
Action Block
Applicant's A-Number
Fee Stamp
Form I-687, Application for Status as a
Temporary Resident Under Section 245A of the INA
Class of AdmissionPlace of Admission
ApprovedDenied
Date of Adjustment
START HERE - Type or print in capital letters in black ink. (If you need more space, use a separate sheet of paper.)
A. Temporary Resident Status as an alien who illegally entered the U.S. prior to January 1, 1982.
1. I hereby apply for status as indicated by the block checked below:
2. Name
B. Temporary Resident Status as an alien who entered the U.S. as a nonimmigrant prior to January 1, 1982, and whose
authorized stay expired before such date or whose unlawful status was known to the Government as of January 1, 1982.
5. Telephone Numbers (including area codes)
Family Name (Last Name)Given Name (First Name)Middle Name
3. Date of Birth
(mm/dd/yyyy)
4.Other A-Nos. and Names Used or Known By (including maiden name, if married)
Home
Work
6. Home Address in the U.S.
In Care Of
Number and Street
CityStateZip Code
Apt. No.
U.S. Social Security No
7. Mailing Address in the U.S. (if different from address in Number 6)
In Care Of
No. and Street Name
City
8. Country of Citizenship
StateZip Code
Apt. No.
Form I-687 06/20/17 Y
Country
9. Place of Birth
City or TownCountry, Province, or State
10. Marital Status
Now MarriedNever MarriedSeparatedDivorcedWidowed
11. Gender12. Race
Male
Female
Asian or Pacific Islander
Hispanic
Black, not of Hispanic origin
White, not of Hispanic origin
Other (specify below)
Form I-687 06/20/17 Y Page 2
13. Have you previously applied for temporary residence as a Legalization applicant?
NoYes
If Yes, give date, place of filing, and final disposition, if known.
14. Do you have other records with USCIS (or the former INS)?
NoYes
If Yes, give file numbers. A-No.Other
15. When did you first come to the U.S.?16. Manner of Entry
Without a visaWith a visa (visitor, student, etc.) specify:
(mm/dd/yyyy)
17. Place of first entry into U.S. to reside:
20. List your present and past husbands/wives and all of your sons and daughters (if additional space is needed, use separate paper).
(Maiden Name, Last Name, First Name)
Port of Entry (City and State):
Border - Not through a Port of Entry (State):
Living A No.
Deceased (year)
18. Mother's Name
Immigration Status
(Last Name, First Name)
Living A No.
Deceased (year)
19. Father's Name
Immigration Status
Family NameGiven NameA-Number
Country of BirthRelationship
Family NameGiven NameA-Number
Country of BirthRelationship
Family NameGiven NameA-Number
Country of BirthRelationship
Family NameGiven NameA-Number
Country of BirthRelationship
Family NameGiven NameA-Number
Country of BirthRelationship
Family NameGiven NameA-Number
Country of BirthRelationship
Form I-687 06/20/17 Y Page 3
If you were admitted as a nonimmigrant prior to January 1, 1982, complete Numbers 21 through 29. If not, leave blank and
go to Number 30.
21. Passport Number
22. Country that Issued Passport23. Location Where Visa Issued (City and Country)
25. Date Visa Issued
(mm/dd/yyyy)
26. Authorized Stay in U.S.
Expired (mm/dd/yyyy)
27. Class of Admission(Student,
Visitor, etc.)
24. Type of Visa Issued
(B-2, F-1, etc.)
28. Did you violate your legal
status prior to January 1, 1982?
NoYes
29. Was your status violation known to the
Government prior to January 1, 1982?
No
Yes If Yes, how was
your status violation
known to the
Government?
30. RESIDENCES IN THE UNITED STATES:
List all of your residences in the United States since your first entry, beginning with your present address. If you need more space
to complete, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each
sheet of paper and indicate on the sheet that the information refers to Number 30.
Zip Code
Number and Street Name
CityState
Apt. No.
From (mm/yyyy)To (mm/yyyy)
Zip Code
Number and Street Name
CityState
Apt. No.
From (mm/yyyy)To (mm/yyyy)
Zip Code
Number and Street Name
CityState
Apt. No.
From (mm/yyyy)To (mm/yyyy)
Zip Code
Number and Street Name
CityState
Apt. No.
From (mm/yyyy)To (mm/yyyy)
Zip Code
Number and Street Name
CityState
Apt. No.
From (mm/yyyy)To (mm/yyyy)
Zip Code
Number and Street Name
CityState
Apt. No.
From (mm/yyyy)To (mm/yyyy)
Zip Code
Number and Street Name
CityState
Apt. No.
From (mm/yyyy)To (mm/yyyy)
Form I-687 06/20/17 Y Page 4
31. AFFILIATIONS OR ASSOCIATIONS: List all affiliations or associations, clubs, organizations, churches, unions, businesses,
etc. to which you belong or have belonged. If you need more space to complete, use a separate sheet of paper. Write your name
and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information
refers to Number 31.
Name of OrganizationLocation (City and State)From(mm/yyyy)To (mm/yyyy)
From(mm/yyyy)To(mm/yyyy)Purpose of TripCountry
Manner of Reentry
(type of visa, EWI)
32. ABSENCES FROM THE UNITED STATES SINCE FIRST ENTRY: List most recent absence first and then all previous
absences dating back to your first entry. If you need more space to complete, use a separate sheet of paper. Write your name and
Alien Registration Number (A-Number), if any, at the top of each sheet of paper and indicate on the sheet that the information
refers to Number 32.
Form I-687 06/20/17 Y Page 5
33. EMPLOYMENT IN THE UNITED STATES SINCE FIRST ENTRY: Show most recent employment first and then all
previous employment dating back to your first entry. If none, write "None." If you need more space to complete, use a separate
sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and
indicate on the sheet that the information refers to Number 33.
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Form I-687 06/20/17 Y Page 6
33. EMPLOYMENT IN THE UNITED STATES SINCE FIRST ENTRY (continued)
34.I have registered under the Military Selective Service Act. My Selective Service Number is:
City
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Number and Street Name
Full Name of Employer
Zip CodeOccupationCityState
Suite No.
Annual WageHourly Wage
From (mm/yyyy)To (mm/yyyy)
Form I-687 06/20/17 Y Page 7
I am a male over the age of 17 and under the age of 26 required to register under the Military Selective Service Act and have
not done so. I wish to register at this time. My SSS Form 1 is attached.
I am a male born after 1959 and over the age of 26 and cannot now register.
I am exempt from Selective Service Registration either because I am a female or I was born before 1960.
35. Have you ever assisted in the persecution of any person or persons on account of race, religion, political
opinion, nationality, or membership in a particular social group?
YesNo
36. Have you ever been treated for a mental disorder, drug addiction, or alcoholism?
NoYes
37. Have you ever committed a crime or offense for which you were not arrested?
NoYes
Have you ever been arrested, cited, or detained by any law enforcement
officer (including USCIS or former INS and military officers) for any reason?
NoYes
Have you ever been charged with committing any crime or offense?
YesNo
Have you ever been convicted of a crime or offense?
NoYes
Have you ever been in jail or prison?
YesNo
Have you ever been placed in an alternative sentencing or a rehabilitative program
(for example: diversion, deferred prosecution, withheld adjudication, deferred adjudication)?
YesNo
Have you ever received a suspended sentence, been placed on probation, or been paroled?
If you answered "Yes" to any of Number 37, complete the following table. If you need more space to complete, use a separate
sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each sheet of paper and
indicate on the sheet that the information refers to Number 37.
NoYes
Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in
such activities in the future?
Attach all certified police reports, indictments, and certified court dispositions for any arrests, citations, detentions,
charges, or imprisonment.
YesNo
Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?
YesNo
Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States
illegally?
YesNo
Why were you arrested, cited, detained,
or charged?
Date arrested, cited,
detained, or charged
(mm/dd/yyyy)
Where were you arrested,
cited, detained, or charged?
(City, State, Country)
Outcome or disposition of the arrest,
citation, detention, or charge
38. Have you, or a dependent member of your immediate family, ever received public assistance from
any source, including, but not limited to, the United States Government, any state, county, city, or
municipality?
YesNo
39. Have you ever:
Form I-687 06/20/17 Y Page 8
Been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?
YesNo
Engaged in, conspired to engage in, or do you intend to engage in, or have you ever solicited
membership or funds for, or have you through any means ever assisted or provided any type of material
support to any person or organization that has ever engaged or conspired to engage in sabotage,
kidnapping, political assassination, hijacking, or any other form of terrorist activity?
YesNo
Engaged in genocide, or otherwise ordered, incited, assisted, or otherwise participated in the killing of
any person because of race, religion, nationality, ethnic origin, or political opinion?
YesNo
Been deported, excluded, or removed from the United States at government expense, or have you ever
been or are you now in exclusion, deportation, removal, or rescission proceedings?
YesNo
Left the United States to avoid being drafted into the United States Armed Forces?
YesNo
Been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement
and have not yet complied with that requirement or obtained a waiver?
YesNo
45. If your native alphabet is in other than Roman letters, write your name in your native alphabet.
46. Language of your native alphabet.
40. Do you intend to engage in the United States in:
A. Espionage?
YesNo
B. Any activity a purpose of which is opposition to, or the control or overthrow of, the government
of the United States, by force, violence, or other unlawful means?
YesNo
C. Any activity to violate or evade any law prohibiting the export from the United States of goods,
technology, or sensitive information?
YesNo
41. Did you, during the period from 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, ever order, incite, assist, or otherwise participate in the persecution of
any person because of race, religion, national origin, or political opinion?
YesNo
42. 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 immigration benefit?
YesNo
YesNo
YesNo
43. Are you now withholding custody of a United States citizen child outside the United States from a
person granted custody of the child?
44. Do you plan to practice polygamy in the United States?
Illicitly trafficked in any controlled substance, or knowingly assisted, abetted, or colluded in the illicit
trafficking of any controlled substance?
YesNo
Form I-687 06/20/17 Y Page 9
Print Preparer's Given Name(First Name)
Preparer's Address
Attorney or Representative Only:
In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
I declare that I prepared this application at the request of the above person(s), and it is based on all information provided to me by the
person(s). I have not knowingly withheld any material information that would affect the outcome of this application.
48. Signature of Person Preparing Form if Other Than Above (Sign below)
YesNo
Date (mm/dd/yyyy)
Preparer's Signature
Print Preparer's Middle NamePrint Preparer's Family Name (Last Name)
E-mail Address(if any)
Preparer's Firm Name (if applicable)
Fax Number(with area code)USCIS Account Number (if any)Daytime Phone Number(with area code)
I CERTIFY,
under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. I
hereby consent and authorize U.S. Citizenship and Immigration Services to verify the information provided and to conduct police,
welfare, and other record checks pertinent to this application.
47. Signature and Certification of Applicant (Sign below)
Date (mm/dd/yyyy)
Signature
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