Application for Family Unity Benefits

• Legal Form Number: I-817
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-817 Edition 12/08/21 Page 1 of 12

For USCIS Use Only

Application for Family Unity Benefits

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-817

OMB No. 1615-0005

Expires 12/31/2023

Remarks

From / / /

To / / /

Action Block

Sent

Received

Relocated

Fee Stamp

Resubmitted

Returned

Initial Application

Valid

Approved Denied

From / / /

To / / /

Request for Extension

Valid

Approved Denied

Part 1. Information About You (Person

Requesting Family Unity Benefits)

2.a. Family Name

(Last Name)

2.b. Given Name

(First Name)

2.c. Middle Name

Provide all other names you have ever used, including aliases,

maiden name, and nicknames. If you need extra space to

complete this section, use the space provided in Part 10.

Additional Information.

3.a.

Family Name

(Last Name)

3.b.

Given Name

(First Name)

3.c.

Middle Name

4.a.

Family Name

(Last Name)

4.b.

Given Name

(First Name)

4.c.

Middle Name

10. Country of C

itizenship or Nationality

9. Country

of Birth

8. Sex Male Female

ZIP Code11.f.State

City or Town

11.e.

11.d

U.S. Mailing Address

11.a. In Care Of Name (if any)

Street Number

and Name

11.b.

11.c. Apt. Flr.Ste.

START HERE - Type or print in black ink.►

To be completed

by an attorney or

BIA-accredited

representative (if any).

Select this box if

Form G-28 is

attached.

Attorney State Bar Number

(if applicable) Attorney or Accredited Representative

USCIS Online Account Number (if any)

USCIS Online Account Number (if any)7.

►

Alien Registration Number (A-Number) (if any)1.

A-

►

NOTE: You must reside and file Form I-817 while in the United States.

5. Date of Birth (mm/dd/yyyy)

Other Information

U.S. Social Security Number (if any)6.

►

Your Full Name

Other Names Used