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Every immigration situation is unique andmay require specific attention or additionalconsideration. This sample is meant to be a basicguide to applicants filling out the forms. Thesample guide shows where to enter in informationand the format for entering the information. If youhave additional questions about your situationplease seek out the help of an immigrationattorney, service provider or law firm.SimpleCitizen, Inc. is not a law firm. The servicesand information provided are not legal advice anddo not substitute the same level of advice, opinion,guidance or recommendation that a licensedimmigration attorney can provide. SimpleCitizen isnot affiliated with the USCIS. The purchase price ofservices does not include USCIS government filingfees.
Application to Register Permanent Residenceor Adjust StatusUSCISForm I-485Department of Homeland SecurityU.S. Citizenship and Immigration ServicesOMB No. 1615-0023Expires 06/30/2019For USCIS Use OnlyReceiptPreference Category:Action BlockCountry Chargeable:Priority Date:Date Form I-693 Received:ApplicantInterviewedDate ofInitial Interview:Section of LawInterviewWaivedINA 209(a)INA 209(b)INA 245(a)INA 245(i)INA 245(m)Lawful PermanentResident as of:INA 249Sec. 13, Act of 9/11/57Cuban Adjustment ActOtherTo be completed by an attorney or accredited representative (if any).Select this box ifForm G-28 isattached.Volag Number(if any)Attorney State Bar Number(if applicable)Attorney or Accredited RepresentativeUSCIS Online Account Number (if any)A-Number A- START HERE - Type or print in black ink.NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in theInstructions, U.S. Citizenship and Immigration Services (USCIS) may deny your application.Part 1. Information About You (Person applyingfor lawful permanent residence)Your Current Legal Name (do not provide anickname)3.a. Family Name(Last Name)3.b. Given Name(First Name)3.c. Middle Name1.a. Family Name GALE(Last Name)1.b. Given Name Matthew(First Name)4.a. Family Name(Last Name)4.b. Given Name(First Name)1.c. Middle Name Richard4.c. Middle NameOther Names You Have Used Since Birth (ifapplicable)Other Information About YouNOTE: Provide all other names you have ever used, includingyour family name at birth, other legal names, nicknames,aliases, and assumed names. If you need extra space tocomplete this section, use the space provided in Part 14.Additional Information.2.a. Family Name GALE(Last Name)2.b. Given Name Matt(First Name)5.Date of Birth (mm/dd/yyyy)05/05/1992NOTE: In addition to providing your actual date of birth,include any other dates of birth you have used inconnection with any legal names or non-legal names inthe space provided in Part 14. Additional Information.6.Sex Male7.City or Town of BirthFemaleLondon2.c. Middle Name RichardForm I-485 06/26/17 NPage 1 of 18
A-Number A-Part 1. Information About You (Person applyingfor lawful permanent residence) (continued)8.Country of BirthNOTE: If you have EVER used other A-Numbers,include the additional A-Numbers in the space providedin Part 14. Additional Information.USCIS Online Account Number (if any) 12.16.Travel Document Number Used at Last Arrival17.Expiration Date of this Passport or Travel DocumentAlien Registration Number (A-Number) (if any) A-11.Passport Number Used at Last Arrival796543567Country of Citizenship or NationalityUnited Kingdom10.Provide the information for Item Numbers 15. - 19. if you lastentered the United States using a passport or travel document.15.United Kingdom9.Recent Immigration History(mm/dd/yyyy)18. United Kingdom19.Nonimmigrant Visa Number from this Passport (if any)Place of Last Arrival into the United States20.a. City or TownNew York CityU.S. Mailing Address20.b. State13.a. In Care Of Name (if any)21.13.c. Apt.Country that Issued this Passport or Travel DocumentL1987498U.S. Social Security Number (if any)13.b. Street Numberand Name08/08/2022Park AvenueSte.Flr.NYDate of Last Arrival (mm/dd/yyyy)08/10/2017When I last arrived in the United States, I:15A13.d. City or TownNew York City13.e. State NY13.f. ZIP Code 1288722.a. Was inspected at a port of entry and admitted as (forexample, exchange visitor; visitor, waived through;temporary worker; student):H-1B Specialty occupation22.b.Was inspected at a port of entry and paroled as (forexample, humanitarian parole, Cuban parole):22.c.Came into the United States without admission orparole.22.d.Other:Alternate and/or Safe Mailing AddressIf you are applying based on the Violence Against Women Act(VAWA) or as a special immigrant juvenile, human traffickingvictim (T nonimmigrant), or victim of a qualifying crime (Unonimmigrant) and you do not want USCIS to send noticesabout this application to your home, you may provide analternative and/or safe mailing address.If you were issued a Form I-94 Arrival-Departure Record Number:14.a. In Care Of Name (if any)23.a. Form I-94 Arrival-Departure Record Number 9 5 3 8 9 8 6 4 3 6 714.b. Street Numberand Name14.c.Apt.23.b. Expiration Date of Authorized Stay Shown on Form I-94Ste.Flr.12/06/201823.c. Status on Form I-94 (for example, class of admission, orparoled, if paroled)14.d. City or Town14.e. State(mm/dd/yyyy)14.f. ZIP CodeForm I-485 06/26/17 NH-1B Specialty occupationPage 2 of 18
A-Number A-Part 1. Information About You (Person applyingfor lawful permanent residence) (continued)24.1.d. Asylee or RefugeeAsylum status (INA section 208), Form I-589 orForm I-730What is your current immigration status (if it has changedsince your arrival)?H-1B Specialty occupationRefugee status (INA section 207), Form I-590 orForm I-7301.e. Human Trafficking Victim or Crime VictimProvide your name exactly as it appears on your Form I-94 (ifany)Human trafficking victim (T Nonimmigrant), FormI-914 or derivative family member, Form I-914A25.a. Family Name GALE(Last Name)25.b. Given Name MATTHEW(First Name)Crime victim (U Nonimmigrant), Form I-918,derivative family member, Form I-918A, orqualifying family member, Form I-92925.c. Middle Name RICHARD1.f.Special Programs Based on Certain Public LawsThe Cuban Adjustment ActPart 2. Application Type or Filing CategoryThe Cuban Adjustment Act for battered spouses andchildrenNOTE: Attach a copy of the Form I-797 receipt or approvalnotice for the underlying petition or application, as appropriate.Dependent status under the Haitian RefugeeImmigrant Fairness ActI am applying to register lawful permanent residence or adjuststatus to that of a lawful permanent resident based on thefollowing immigrant category (select only one box). (See theForm I-485 Instructions for more information, including anyAdditional Instructions that relate to the immigrant categoryyou select.):Dependent status under the Haitian RefugeeImmigrant Fairness Act for battered spouses andchildrenLautenberg ParoleesDiplomats or high ranking officials unable to returnhome (Section 13 of the Act of September 11, 1957)1.a. Family-basedIndochinese Parole Adjustment Act of 2000 Immediate relative of a U.S. citizen, Form I-130Other relative of a U.S. citizen or relative of a lawfulpermanent resident under the family-based preferencecategories, Form I-1301.g. Additional OptionsDiversity Visa programContinuous residence in the United States sincebefore January 1, 1972 ("Registry")Person admitted to the United States as a fiancé(e) orchild of a fiancé(e) of a U.S. citizen, Form I-129F(K-1/K-2 Nonimmigrant)Individual born in the United States under diplomaticstatusWidow or widower of a U.S. citizen, Form I-360Other eligibilityVAWA self-petitioner, Form I-3601.b. Employment-basedAlien worker, Form I-140Alien entrepreneur, Form I-5261.c. Special ImmigrantReligious worker, Form I-360Special immigrant juvenile, Form I-360Certain Afghan or Iraqi national, Form I-360Certain international broadcaster, Form I-360Certain G-4 international organization or familymember or NATO-6 employee or family member,Form I-360Form I-485 06/26/17 N2.Are you applying for adjustment based on theImmigration and Nationality Act (INA) section 245(i)?Yes NoNOTE: If you answered "Yes" to Item Number 2., youmust have selected a family-based, employment-based,special immigrant, or Diversity Visa immigrant categorylisted above in Item Numbers 1.a. - 1.g. as the basis foryour application for adjustment of status. Fill out the restof this application and Supplement A to Form I-485,Adjustment of Status Under Section 245(i) (SupplementA). For detailed filing instructions, read the Form I-485Instructions (including any Additional Instructions thatrelate to the immigrant category that you selected in ItemNumbers 1.a. - 1.g.) and Supplement A Instructions.Page 3 of 18
A-Number A-Part 2. Application Type or Filing Category(continued)Information About Your Immigrant CategoryIf you are the principal applicant, provide the followinginformation.3.Receipt Number of Underlying Petition (if any)4.Priority Date from Underlying Petition (if any)(mm/dd/yyyy)3.Decision (for example, approved, refused, denied,withdrawn)4.Date of Decision (mm/dd/yyyy)Address HistoryProvide physical addresses for everywhere you have livedduring the last five years, whether inside or outside the UnitedStates. Provide your current address first. If you need extraspace to complete this section, use the space provided inPart 14. Additional Information.If you are a derivative applicant (the spouse or unmarriedchild under 21 years of age of a principal applicant), provide thefollowing information for the principal applicant.Physical Address 1 (current address)Principal Applicant's Name5.b.5.a. Family Name(Last Name)5.b. Given Name(First Name)5.c. Middle Name6.Principal Applicant's A-Number (if any)Principal Applicant's Date of BirthReceipt Number of Principal's Underlying Petition (if any) 9.Priority Date of Principal Applicant's Underlying PetitionSte.Flr.15ANew York City5.d. State NY5.e. ZIP Code 12887Province5.g. Postal Code5.h. CountryUnited States(mm/dd/yyyy)8. Apt.Park Avenue5.c. City or Town5.f. A-7.5.a. Street Numberand NameDates of Residence6.a. From (mm/dd/yyyy)01/05/2010Present6.b. To (mm/dd/yyyy)(if any) (mm/dd/yyyy)Physical Address 2Part 3. Additional Information About You7.a. Street Numberand Name1.Have you ever applied for an immigrant visa to obtainpermanent resident status at a U.S. Embassy or U.S.Consulate abroad?Yes No7.b.If you answered "Yes" to Item Number 1., completeItem Numbers 2.a. - 4. below. If you need extra space tocomplete this section, use the space provided in Part 14.Additional Information.7.d. StateApt.Ste.Flr.7.c. City or Town7.f.7.e. ZIP CodeProvinceLocation of U.S. Embassy or U.S. Consulate7.g. Postal Code2.a. City7.h. Country2.b. CountryForm I-485 06/26/17 NPage 4 of 18
A-Number A-Part 3. Additional Information About You(continued)Address of Employer or CompanyDates of Residence12.b.8.a. From (mm/dd/yyyy)8.b. To (mm/dd/yyyy)Provide your most recent address outside the United Stateswhere you lived for more than one year (if not already listedabove).9.a. Street NumberCambridge Roadand Name9.b.Apt.Ste.12.a. Street Numberand NameApt.111 8th AvenueSte.Flr.12.c. City or TownNew York12.d. State NY12.e. ZIP Code 1001112.f. Province12.g. Postal Code12.h. CountryFlr.United States13.Your Occupation9.c. City or TownGreat Shelford9.d. State9.e. ZIP Code9.f.England14.a. From (mm/dd/yyyy)CB22 5JU14.b. To (mm/dd/yyyy)Software EngineerProvince9.g. Postal CodeDates of Employment01/05/2010Present9.h. CountryEmployer 2United Kingdom15.Dates of Residence10.a. From (mm/dd/yyyy)01/01/200810.b. To (mm/dd/yyyy)01/05/2010Name of Employer or CompanyAddress of Employer or Company16.a. Street Numberand NameEmployment History16.b.Provide your employment history for the last five years,whether inside or outside the United States. Provide the mostrecent employment first. If you need extra space to completethis section, use the space provided in Part 14. AdditionalInformation.16.c. City or TownEmployer 1 (current or most recent)11.Name of Employer or CompanyGoogleApt.Ste.16.d. StateFlr.16.e. ZIP Code16.f. Province16.g. Postal Code16.h. Country17.Your OccupationDates of Employment18.a. From (mm/dd/yyyy)18.b. To (mm/dd/yyyy)Form I-485 06/26/17 NPage 5 of 18
A-Number A-Part 3. Additional Information About You(continued)Provide your most recent employment outside of the UnitedStates (if not already listed above).19.Date of Birth (mm/dd/yyyy)4.Sex5.City or Town of Birth6.Apt.7.University RoadSte. FemaleCountry of BirthUnited KingdomAddress of Employer or Company20.a. Street Numberand NameMaleCurrent City or Town of Residence (if living)LondonFlr.8.Current Country of Residence (if living)United Kingdom20.c. City or TownCambridge20.d. State20.e. ZIP CodeInformation About Your Parent 220.f. ProvinceCambridgeParent 2's Legal Name20.g. Postal CodeCB22 5JU9.a. Family Name(Last Name) GALE9.b. Given Name(First Name) Richard20.h. CountryUnited Kingdom21.9.c. Middle Name PaulYour OccupationParent 2's Name at Birth (if different than above)BaristaDates of Employment22.a. From (mm/dd/yyyy)11/02/200822.b. To (mm/dd/yyyy)05/01/200910.a. Family Name(Last Name)10.b. Given Name(First Name)10.c. Middle Name11.Date of Birth (mm/dd/yyyy)Part 4. Information About Your Parents12.SexInformation About Your Parent 113.City or Town of BirthParent 1's Legal Name1.a. Family Name(Last Name) HENDRY1.b. Given Name(First Name) WendyParent 1's Name at Birth (if different than above) Male07/27/1963FemaleLondon14.Country of BirthUnited Kingdom15.1.c. Middle Name Lin2.a. Family Name(Last Name) LEWIS2.b. Given Name(First Name) Wendy04/29/1969LondonName of Employer or CompanyCambridge University