Application for Status as a Temporary Resident Under Section 245A of the Immigration and Nationality Act

• Legal Form Number: I-687
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

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 Admission Place of Admission

Approved Denied

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

City State Zip 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

State Zip Code

Apt. No.

Form I-687 06/20/17 Y

Country

9. Place of Birth

City or Town Country, Province, or State

10. Marital Status

Now Married Never Married Separated Divorced Widowed

11. Gender 12. Race

Male

Female

Asian or Pacific Islander

Hispanic

Black, not of Hispanic origin

White, not of Hispanic origin

Other (specify below)