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Adjustment of Status Questionnaire
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Please note: Failure to complete all sections may result in substantial delay in the processing of this case. We may however require additional information following review. If a question does not apply, please put "none" or "not applicable" (N/A). Please note that you must be physically present in the U.S. at the time of filing the adjustment of status applications(s).

Before starting the questionnaire, we advise you to print the questionnaire using your browser's print function and review all fields to ensure that you have the required information available. The questionnaire is quite lengthy, and closing or refreshing your browser prior to submitting the questionnaire will result in the loss of your completed data. Additionally, you may want to print the questionnaire after you've completed the information, but prior to clicking "Submit," so that you have a copy for your records.

Please note that this form contains personal information you provided that constitutes sensitive personal information (SPI), which is specially protected under data protection laws of certain countries. Where Fragomen has been engaged by your or your spouse’s employer*, Fragomen will not share the SPI received in this form with the employer unless it is deemed necessary and we have your express consent to do so.

In the event that any information provided herein may have consequences with respect to the immigration benefit sought (such as a delay or denial), Fragomen may determine it is necessary to share such information with the employer and will seek your consent before doing so.

*If you are the dependent of a primary applicant and engage Fragomen directly, an attorney/client relationship shall exist between you and Fragomen and it will not be necessary to share information with the employer.
● Remember to complete a new questionnaire and create forms for every dependent/spouse and minor children not born in the U.S. and who will apply for Adjustment of Status with you.
● If you identify corrections that are needed after you generate the forms, please contact your Fragomen professional.

Where Fragomen has been engaged by your employer, the attorney-client relationship is between your employer and Fragomen. The attorney-client privilege is held by your employer, and your employer shall have sole discretion with respect to when and under what circumstances the privilege may be waived. Fragomen shall process your personal information in accordance with the firm’s Privacy Notice, including with respect to when information you provide in this questionnaire may be disclosed to your employer. Please note that this questionnaire requires that you provide personal information that constitutes sensitive personal information (SPI), which is specially protected under data protection laws of certain countries. Fragomen will not share the SPI received in this form with them unless it is necessary and we have your express consent to do so. In the event that any information provided herein may have consequences with respect to the immigration benefit sought (such as a delay or denial), Fragomen may determine it is necessary to share such information with your employer and will seek your consent before doing so.

By clicking “I Accept”, you will be giving your consent to our processing your personal data as described in our Privacy Notice. If it is necessary to process sensitive personal data (as described in the “Sensitive Personal Data” section of the Notice and which is specially protected under data protection laws of certain countries) as part of the specific immigration services being provided, you agree to our use of your Sensitive Personal Data as described in our Privacy Notice. Where necessary, you also consent to our sharing this data outside of your home country with government agencies and certain third-party service providers, as described in the “Information We Share” section of the Notice.

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Personal Information - Biographic Information
The Applicant name should be entered as it appears on your passport.
*Last Name:
*First Name:
*Middle Name:
Suffix:
*Have you used any other names, including maiden name and names from a previous marriage?
*Gender:
*U.S. Social Security Number: - -
Alien Number (If any):
*Date of Birth:
*City or Town of Birth:
*Country of Birth:
State/Province/Region of Birth:
*Country of Citizenship:
If dual citizen, please provide other Country of Citizenship:
*Your most recently issued passport:
*Passport Expiration Date:
*Passport Issued by (Country):
*The passport used when you last arrived in the US:
*Passport Expiration Date:
*Passport Issued by (Country):
*Date of Last Entry into the U.S.:
*Form I-94 Number (Arrival and Departure Record). If not issued, enter "N/A":
From traditional I-94 card or I-94 printout from http://www.cbp.gov/i94
Name exactly as it appears on your Form I-94 card (LAST, First):
*Last Name:
*First Name:
Middle Name:
*Place of Last Entry into the U.S. City or Town and State:
*When you last made an entry to the US, what visa status did you use? ( e.g. H-1B, H-4, F-1)
Current U.S. Immigration Status:
(H-1B, L-1A, etc.) (If it has changed since your last entry)
Please indicate if you are a permanent resident, landed immigrant, national or citizen of any other country. If so, please identify:
*Expiration of Status as shown on Form I-94 or Form I-688:
or
*Visa Number from Visa Used at Last Entry (8-digit visa number):
Red number on the lower right of the visa stamp.
If you are visa exempt please enter "visa exempt"
or
*Place of Visa Issuance (City):
*Date of Visa Issuance:
*Have you or your accompanying family members ever applied for U.S. permanent residence (e.g., Green Card)?
*Have you previously applied for an Employment Authorization Document (EAD)?
*Has the Social Security Administration (SSA) ever officially issued a Social Security card to you?
*Do you want the SSA to issue you a Social Security card in connection with your approved I-765 employment authorization application (SSN card annotated with DHS authorization restriction)?
*Do you want the SSA to issue you a new or replacement Social Security card (with unrestricted ability to work) upon approval of your I-485 green card application?
*I authorize disclosure of information from this application to the SSA as required for the purpose of assigning me a SSN and issuing me a Social Security card:
*Have you ever been in J-1 or J-2 status or been issued a J-1 or J-2 visa?
*I am filing form I-485 as a
Do you hold:
VAWA self-petitioner status
Victim of Qualifying Criminal Activity (U nonimmigrant) status
Human trafficking victim (T nonimmigrant) status
Home Address in the USA
*Street Address:
*City:
*Country
*State/Province/Region:
*ZIP Code:
*Date at this Address From:
*Date at this Address To:
*E-mail Address:
Home Telephone Number:
Cellular Number:
*Daytime Telephone Number:
Fax Number:
Personal Information - Biometrics
*Ethnicity:
Race (Select all applicable boxes):



*Height: Feet Inches
*Weight: Pounds
*Eye Color:



*Hair Color:



Family Information
*What is your current marital status?




Previous Spouse
*Have you previously been married?
 
Spouse
*Do you have a spouse?
Children
*Do you have any living child(ren)? Children are defined as all biological or legally adopted children, as well as current stepchildren of any age, whether born in the United States or other countries, married or unmarried, living with you or elsewhere and includes any missing children and those born to you outside of marriage.
 
Father
*Last Name:
*First Name:
Middle Name (If Any):
Name at Birth (If Different than Above):
Last Name:
First Name:
Middle Name:
*Date of Birth:
*City or Town of Birth:
*Country of Birth:
*State or Province of Birth:
Is this Parent Deceased?
Address:
*City or Town:
*Country:
State/Province/Region:
ZIP Code:
Mother
*Last Name:
*First Name:
Middle Name (If Any):
Name at Birth if Different than Above (i.e. Maiden Name):
*Last Name:
*First Name:
Middle Name:
*Date of Birth:
*City or Town of Birth:
*Country of Birth:
*State or Province of Birth:
Is this Parent Deceased?
Address:
*City or Town:
*Country:
State/Province/Region:
ZIP Code:
Past Residence Information:
Provide all residence information for the past five (5) years, not including current address. Please provide previous addresses in chronological order, most recent first.
Previous Address 1:
Date From:
Date To:
Street Address:
 
City:
Country:
State/Province/Region:
ZIP Code:
Previous Address 2:
Date From:
Date To:
Street Address:
 
City:
Country:
State/Province/Region:
ZIP Code:
Previous Address 3:
Date From:
Date To:
Street Address:
 
City:
Country:
State/Province/Region:
ZIP Code:
Previous Address 4:
Date From:
Date To:
Street Address:
 
City:
Country:
State/Province/Region:
ZIP Code:
Previous Address 5:
Date From:
Date To:
Street Address:
 
City:
Country:
State/Province/Region:
ZIP Code:
Previous Address 6:
Date From:
Date To:
Street Address:
 
City:
Country:
State/Province/Region:
ZIP Code:
Provide Last Address Outside the U.S. (Where You Resided for at Least One Year)
*Street Address:
Address Line 2:
*City:
*Country:
*State/Province/Region:
*Postal Code:
*Date at this Address From:
*Date at this Address To:
Most Recent Employment Outside the U.S.
Name of Employer:
Title:
Street Address:
City:
Country:
State/Province/Region:
Postal Code:
Date at this Employment From:
Date at this Employment To:
Employment Information For Last Five (5) Years (Including Present Employment)
Please use the Add Employment link below to provide all employment information for the past five (5) years, start with present employment first. If you held substantially different jobs/titles at the same employer, please enter them as separate employment items.
For any period in the past 5 years that you were not employed, you must still complete the questionnaire for that period of time by writing "UNEMPLOYED" and then indicating the dates that you were not employed, and write "N/A" for name of employer.
Click the Add Employment button. A new window will pop-up, allowing you to add information.
To add additional employment, just click on the Add Employment button again
Miscellaneous Required Questions
*1Have you EVER been denied admission to the United States?
*2Have you EVER been denied a visa to the United States?
*3Have you EVER worked in the United States without authorization?
*4Have you EVER violated the terms or conditions of your nonimmigrant status?
*5Are you presently or have you EVER been in removal, exclusion, rescission, or deportation proceedings?
*6Have you EVER been issued a final order of exclusion, deportation, or removal?
*7Have you EVER had a prior final order of exclusion, deportation, or removal reinstated?
*8Have you EVER held lawful permanent resident status which was later rescinded?
*9Have you EVER been granted voluntary departure by an immigration officer or an immigration judge but failed to depart within the allotted time?
*10Have you EVER applied for any kind of relief or protection from removal, exclusion, or deportation?
*11aHave you ever been a J nonimmigrant exchange visitor who was subject to the two-year foreign residence requirement?
*11bIf yes, have you complied with the foreign residence requirement?
*11cIf yes, have you been granted a waiver or has Department of State issued a favorable waiver recommendation letter for you?
*12Have you EVER been arrested, cited, charged, or detained for any reason by any law enforcement official (including but not limited to any U.S. immigration official or any official of the U.S. armed forces or U.S. Coast Guard)?
*13Have you EVER committed a crime of any kind (even if you were not arrested, cited, charged with, or tried for that crime)?
*14Have you EVER pled guilty to or been convicted of a crime or offense (even if the violation was subsequently expunged or sealed by a court, or if you were granted a pardon, amnesty, a rehabilitation decree, or other act of clemency)?
*15Have you EVER been ordered punished by a judge or had conditions imposed on you that restrained your liberty (such as a prison sentence, suspended sentence, house arrest, parole alternative sentencing, drug or alcohol treatment, rehabilitative programs or classes, probation, or community service)?
*16Have you EVER been a defendant or the accused in a criminal proceeding (including pre-trial diversion, deferred prosecution, deferred adjudication, or any withheld adjudication)?
*17Have you EVER violated (or attempted or conspired to violate) any controlled substance law or regulation of state, the United States, or a foreign country?
*18Have you EVER been convicted of two or more offenses (other than purely political offenses) for which the combined sentences to confinement were five years or more?
*19Have you EVER illicitly (illegally) trafficked or benefited from the trafficking of any controlled substances, such as chemicals, illegal drugs, or narcotics?
*20Have you EVER knowingly aided, abetted, assisted, conspired, or colluded in the illicitly trafficking of any illegal narcotic or other controlled substances?
*21Are you the spouse, son, or daughter of a foreign national who illicitly trafficked or aided (or otherwise abetted, assisted, conspired, or colluded) in the illicit trafficking of a controlled substance, such as chemicals, illegal drugs, or narcotics and you obtained, within the last five years, any financial or other benefit from the illegal activity of your spouse or parent, although you knew or reasonably should have known that the financial or other benefit resulted from the illicit activity of your spouse or parent?
*22Have you EVER engaged in prostitution or are you coming to the United States to engage in prostitution?
*23Have you EVER directly or indirectly procured (or attempted to procure) or imported prostitutes or persons for the purpose of prostitution?
*24Have you EVER received any proceeds or money from prostitution?
*25Do you intend to engage in illegal gambling or any other form of commercialized vice, such as prostitution, bootlegging, or the sale of child pornography, while in the United States?
*26Have you EVER exercised immunity (diplomatic or otherwise) to avoid being prosecuted for a criminal offense in the United States?
*27Have you EVER, while serving as a foreign government official, been responsible for or directly carried out violations of religious freedoms?
*28Have you EVER induced by force, fraud, or coercion (or otherwise been involved in) the trafficking of persons for commercial sex acts?
*29Have you EVER trafficked a person into involuntary servitude, peonage, debt bondage, or slavery? Trafficking includes recruiting, harboring, transporting, providing, or obtaining a person for labor or services through the use of force, fraud, or coercion.
*30Have you EVER knowingly aided, abetted, assisted, conspired, or colluded with others in trafficking persons for commercial sex acts or involuntary servitude, peonage, debt bondage, or slavery?
*31Are you the spouse, son or daughter of a foreign national who engaged in the trafficking of persons and have received or obtained, within the last five years, any financial or other benefits from the illicit activity of your spouse or your parent, although you knew or reasonably should have known that this benefit resulted from the illicit activity of your spouse or parent?
*32Have you EVER engaged in money laundering or have you EVER knowingly aided, assisted, conspired, or colluded with others in money laundering or do you seek to enter the United States to engage in such activity?
Do you intend to:
*33aEngage in any activity that violates or evades any law relating to espionage (including spying) or sabotage in the United States?
*33bEngage in any activity in the United States that violates or evades any law prohibiting the export from the United States of goods, technology, or sensitive information?
*33cEngage in any activity whose purpose includes opposing, controlling, or overthrowing the U.S. Government by force, violence, or other unlawful means while in the United States?
*33dEngage in any activity that could endanger the welfare, safety, or security of the United States?
*33eEngage in any other unlawful activity?
*34Are you engaged in or, upon your entry into the United States, do you intend to engage in any activity that could have potentially serious adverse foreign policy consequences for the United States?
Have you EVER:
*35aCommitted, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use of a weapon or explosive to harm another individual or cause substantial damage to property?
*35bParticipated in, or been a member of, a group or organization that did any of the activities described above?
*35cRecruited members or asked for money or things of value for a group or organization that did any of the activities described above?
*35dProvided money, a thing of value, services or labor, or any other assistance or support for any of the activities described above?
*35eProvided money, a thing of value, services or labor, or any other assistance or support for an individual, group, or organization who did any of the activities described above?
*36Have you EVER received any type of military, paramilitary, or weapons training?
*37Do you intend to engage in any of the activities listed in any part of Item Numbers 35.a. - 36?
Are you the spouse or child of an individual who EVER:
*38aCommitted, threatened to commit, attempted to commit, conspired to commit, incited, endorsed, advocated, planned, or prepared any of the following: hijacking, sabotage, kidnapping, political assassination, or use of a weapon or explosive to harm another individual or cause substantial damage to property?
*38bParticipated in, or been a member or a representative of a group or organization that did any of the activities described above?
*38cRecruited members or asked for money or things of value, for a group or organization that did any of the activities described above?
*38dProvided money, a thing of value, services or labor, or any other assistance or support for any of the activities described above?
*38eProvided money, a thing of value, services or labor, or any other assistance or support for an individual, group, or organization who did any of the activities described above?
*38fReceived any type of military, paramilitary, or weapons training from a group or organization that did any of the activities described above?
*39Have you EVER assisted or participated in selling, providing, or transporting weapons to any person who, to your knowledge, used them against another person?
*40Have you EVER worked, volunteered, or otherwise served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons
*41Have you EVER been a member of, assisted, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so?
*42Have you EVER served in, been a member of, assisted, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerilla group, militia, insurgent organization, or any other armed group?
*43Have you EVER been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party (in the United States or abroad)?
*44During the period from March 23, 1933 to May 8, 1945, did you ever order, incite, assist, or otherwise participate in the persecution of any person because of race, religion, national origin, or political opinion, in association with either the Nazi government of Germany or any organization or government associated or allied with the Nazi government of Germany?
Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:
*45aActs involving torture or genocide?
*45bKilling any person?
*45cIntentionally and severely injuring any person?
*45dEngaging in any kind of sexual contact or relations with any person who did not consent or was unable to consent, or was being forced or threatened?
*45eLimiting or denying any person’s ability to exercise religious beliefs?
*46Have you EVER recruited, enlisted, conscripted, or used any person under 15 years of age to serve in or help an armed force or group?
*47Have you EVER used any person under 15 years of age to take part in hostilities, or to help or provide services to people in combat?
*48Have you received public assistance in the United States from any source, including the U.S. Government or any state, county, city, or municipality (other than emergency medical treatment)?
*49Are you likely to receive public assistance in the future in the United States from any source, including the U.S. Government or any state, county, city, or municipality (other than emergency medical treatment)?
*50aHave you EVER failed or refused to attend or to remain in attendance at any removal proceeding filed against you on or after April 1, 1997?
*50bIf yes, do you believe you had reasonable cause?
*50cIf your answer to Item Number 50.b. is "Yes," submit a written statement explaining why you had reasonable cause.
*51 Have you EVER submitted fraudulent or counterfeit documentation to any U.S. Government official to obtain or attempt to obtain any immigration benefit, including a visa or entry into the United States?
*52Have you EVER lied about, concealed, or misrepresented any information on an application or petition to obtain a visa, other documentation required for entry into the United States, admission to the United States, or any other kind of immigration benefit?
*53Have you EVER falsely claimed to be a U.S. citizen (in writing or any other way)?
*54Have you EVER been a stowaway on a vessel or aircraft arriving in the United States?
*55Have you EVER knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or to try to enter the United States illegally (alien smuggling)?
*56Are you under a final order of civil penalty for violating INA section 274C for use of fraudulent documents?
*57Have you EVER been excluded, deported, or removed from the United States or have you ever departed the United States on your own after having been ordered excluded, deported, or removed from the United States?
*58Have you EVER entered the United States without being inspected and admitted or paroled?
Since April 1, 1997, have you been unlawfully present in the United States:
*59aFor more than 180 days but less than a year, and then departed the United States?
*59bFor one year or more and then departed the United States?
Since April 1, 1997, have you EVER reentered or attempted to reenter the United States without being inspected and admitted or paroled after:
*60aHaving been unlawfully present in the United States for more than one year in the aggregate?
*60bHaving been deported, excluded, or removed from the United States?
*61Do you plan to practice polygamy in the United States?
*62Are you accompanying another foreign national who requires your protection or guardianship but who is inadmissible after being certified by a medical officer as being helpless from sickness, physical or mental disability, or infancy, as described in INA section 232(c)?
*63 Have you EVER assisted in detaining, retaining, or withholding custody of a U.S. citizen child outside the United States from a U.S. citizen who has been granted custody of the child?
*64Have you EVER voted in violation of any Federal, state, or local constitutional provision, statute, ordinance, or regulation in the United States?
*65Have you EVER renounced U.S. citizenship to avoid being taxed by the United States?
Have you EVER:
*66aApplied for exemption or discharge from training or service in the U.S. armed forces or in the U.S. National Security Training Corps on the ground that you are a foreign national?
*66bBeen relieved or discharged from such training or service on the ground that you are a foreign national?
*66cBeen convicted of desertion from the U.S. armed forces?
*67aHave you EVER left or remained outside the United States to avoid or evade training or service in the U.S. armed forces in time of war or a period declared by the President to be a national emergency?
*67bIf yes, what was your nationality or immigration status immediately before you left (for example, U.S. citizen or national, lawful permanent resident, nonimmigrant, parolee, present without admission or parole, or any other status)?
*68Have you ever before been issued a reentry permit or Refugee Travel Document?
Memberships

*Have you EVER been a member of, involved in, or in any way associated with any organization, association, fund, foundation, party, club, society, or similar group in the United States or in any other location in the world including any military service?
List your present and past membership in or affiliation with every organization, association, fund, foundation, party, club, society or similar group in the U.S. or in any other places since your 16th birthday. Include any military service in this part. Include the name of each organization, location, nature and dates of membership. If "None", then write "NONE".

Disability and/or Impairment Accommodations
*Are you requesting an accommodation because of your disability(ies) and/or impairment(s)?
a) I am deaf or hard of hearing and request the following accommodation(s) [if requesting a sign-language interpreter, indicate which language (e.g., American Sign Language)]
b) I am blind or sight-impaired and request the following accommodation(s)
c) I have another type of disability and/or impairment (describe the nature of your disability(ies) and/or impairment(s) and the accommodation(s) you are requesting:


Public Charge
Are you subject to the public charge ground of inadmissability under INA section 212 (a)(4)? If you are applying for adjustment of status as an employment-based, family-based, or diversity visa applicant, please answer yes.
Carefully review the information provided.
You can review your forms before finalizing the questionnaire by clicking the "Preview" button.
Once you select to "Submit" you will not be able to make any changes.


  • Your biographic details, residence(s), contact information, marital history, work/education history, current immigration status and immigration history.
  • Information about your family members, including their names, biographic details, residence(s), contact details, marital history, work/education history, current immigration status and immigration history.

By submitting this questionnaire, you confirm that you have reviewed
all responses and that each response is true, complete and correct.

You also confirm that each supporting document you provide to Fragomen
is an unaltered original or a true copy thereof.

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