PDF Test For USCIS Use Only A Initial Receipt Resubmitted Fee Stamp Sent 201b Spouse IR1CR1 201b Spouse IR1CR1 201b Child IR2CR2 201b Child IR2CR2 201b Parent IR5 201b Parent IR5 203a1 Unm SD F11 203a1 Unm SD F11 203a2A Spouse F21 203a2A Spouse F21 203a2A Child F22 203a2A Child F22 203a2B Unm SD F24 203a2B Unm SD F24 203a3 Married SD F31 203a3 Married SD F31 203a4 BrotherSister F41 203a4 BrotherSister F41 Action Stamp Approved Petition was filed on Priority Date mmddyyyy Returned PDR request granteddenied New priority date mmddyyyy Field Investigation Field Investigation Previously Forwarded Previously Forwarded 203g Resolved 203g Resolved Personal Interview Personal Interview Pet AFile Reviewed Pet AFile Reviewed Ben AFile Reviewed Ben AFile Reviewed 204a2A Resolved 204a2A Resolved I485 Filed Simultaneously I485 Filed Simultaneously 204g Resolved 204g Resolved Remarks At which USCIS office eg NBC VSC LOS CRO was Form I130 adjudicated Select this box if Select this box if if any if applicable USCIS Online Account Number if any Spouse Spouse Parent Parent BrotherSister BrotherSister Child Child Child was born to parents who were married to each Child was born to parents who were married to each StepchildStepparent StepchildStepparent Child was born to parents who were not married to Child was born to parents who were not married to Child was adopted not an Orphan or Hague Child was adopted not an Orphan or Hague Yes Yes Did you gain lawful permanent resident status or NoNo_2 Yes_2 Yes_2 A_2 undefined undefined_2 Family Name First Name Middle Name Form I130 021319 Page 1 of 12 Family Name_2 First Name_2 Middle Name_2 CityTownVillage of Birth Country of Birth Date of Birth mmddyyyy Sex MaleFemale In Care Of Name Street Number Apt Apt Ste Ste undefined_3 undefined_3 Flr City or Town State 10f ZIP Code Province Postal Code Country Is your current mailing address the same as your physical No_3Yes_3 Street Number_2 Apt_2 Apt_2 Ste_2 Ste_2 undefined_4 undefined_4 Flr_2 City or Town_2 State_2 12e ZIP Code Province_2 Postal Code_2 Country_2 undefined_5 Street Number_3 Apt_3 Apt_3 Ste_3 Ste_3 undefined_6 undefined_6 Flr_3 City or Town_3 State_3 14e ZIP Code Province_3 Postal Code_3 Country_3 undefined_7 undefined_8 undefined_9 Single Never Married Single Never Married Married Married Divorced Divorced Widowed Widowed Separated Separated Annulled Annulled Form I130 021319_2 Page 2 of 12 Date of Current Marriage if currently married 19a City or Town undefined_10 19c Province 19d Country 20a Family Name First Name_3 20c Middle Name Date Marriage Ended mmddyyyy Family Name_3 First Name_4 22c Middle Name Date Marriage Ended mmddyyyy_2 Family Name_4 First Name_5 Middle Name_3 Date of Birth mmddyyyy_2 Sex_2 Male_2Female_2 Country of Birth_2 CityTownVillage of Residence Country of Residence Family Name_5 First Name_6 Middle Name_4 Date of Birth mmddyyyy_3 Sex_3 Female_3Male_3 Country of Birth_3 CityTownVillage of Residence_2 Country of Residence_2 US Citizen US Citizen Lawful Permanent Resident Lawful Permanent Resident Birth in the United States Birth in the United States Naturalization Naturalization Parents Parents Have you obtained a Certificate of Naturalization or a No_4Yes_4 39a Certificate Number 39b Place of Issuance 39c Date of Issuance mmddyyyy 40a Class of Admission 40b Date of Admission mmddyyyy 40c City or Town Did you gain lawful permanent resident status through marriage to a US citizen or lawful permanent resident No_5Yes_5 Name of EmployerCompany Street Number_4 Apt_4 Apt_4 Ste_4 Ste_4 Flr_4 Flr_4 undefined_11 43c City or Town 43d State 43e ZIP Code Province_4 43g Postal Code Country_4 Your Occupation undefined_12 Name of EmployerCompany_2 Street Number_5 Apt_5 Apt_5 Ste_5 Ste_5 Flr_5 Flr_5 undefined_13 47c City or Town 47d State 47e ZIP Code Province_5 47g Postal Code Country_5 Your Occupation_2 undefined_14 undefined_15 Part 3 Biographic Information Hispanic or Latino Hispanic or Latino Not Hispanic or Latino Not Hispanic or Latino White White Asian Asian Black or African American Black or African American American Indian or Alaska Native American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Native Hawaiian or Other Pacific Islander Feet Inches Pounds Pounds undefined_16 undefined_16 undefined_17 Black Black Gray Gray Maroon Maroon Blue Blue Green Green Pink Pink Brown Brown Hazel Hazel UnknownOther UnknownOther Form I130 021319_3 Page 4 of 12 Bald No hair Bald No hair Brown_2 Brown_2 Sandy Sandy Black_2 Black_2 Gray_2 Gray_2 White_2 White_2 Blond Blond Red Red UnknownOther_2 UnknownOther_2 A_3 undefined_18 undefined_19 Family Name_6 First Name_7 Middle Name_5 Family Name_7 First Name_8 Middle Name_6 CityTownVillage of Birth_2 Country of Birth_4 Date of Birth mmddyyyy_4 Sex_4 Female_4Male_4 Has anyone else ever filed a petition for the beneficiary UnknownYes_6No_6 Street Number_6 Apt_6 Apt_6 Ste_6 Ste_6 undefined_20 undefined_20 Flr_6 City or Town_4 State_4 11e ZIP Code Province_6 Postal Code_4 Country_6 Street Number_7 Apt_7 Apt_7 Ste_7 Ste_7 undefined_21 undefined_21 Flr_7 City or Town_5 State_5 12e ZIP Code_2 Street Number_8 Apt_8 Apt_8 Ste_8 Ste_8 undefined_22 undefined_22 Flr_8 13c City or Town 13d Province 13e Postal Code 13f Country Daytime Telephone Number if any Mobile Telephone Number if any Email Address if any undefined_23 Single Never Married_2 Single Never Married_2 Married_2 Married_2 Divorced_2 Divorced_2 Widowed_2 Widowed_2 Separated_2 Separated_2 Annulled_2 Annulled_2 Date of Current Marriage if currently married_2 City or Town_6 undefined_24 Province_7 Country_7 21a Family Name First Name_9 21c Middle Name Date Marriage Ended mmddyyyy_3 Spouse 2 23a Family Name First Name_10 23c Middle Name Date Marriage Ended mmddyyyy_4 25a Family Name First Name_11 25c Middle Name Relationship Date of Birth mmddyyyy_5 Country of Birth_5 Person 2 29a Family Name First Name_12 29c Middle Name Relationship_2 Date of Birth mmddyyyy_6 Country of Birth_6 Person 3 Family Name_8 First Name_13 33c Middle Name Relationship_3 Date of Birth mmddyyyy_7 Country of Birth_7 Family Name_9 First Name_14 37c Middle Name Relationship_4 Date of Birth mmddyyyy_8 Country of Birth_8 Person 5 41a Family Name First Name_15 41c Middle Name Relationship_5 Date of Birth mmddyyyy_9 Country of Birth_9 Was the beneficiary EVER in the United States Yes_7No_7 46a He or she arrived as a Class of Admission undefined_25 46c Date of Arrival mmddyyyy Form I94 or Form I95 mmddyyyy or type or print Passport Number Travel Document Number Country of Issuance for Passport or Travel Document Expiration Date for Passport or Travel Document Name of Current Employer if applicable Street Number_9 Apt_9 Apt_9 Ste_9 Ste_9 undefined_26 undefined_26 Flr_9 City or Town_7 51e State 51f ZIP Code 51g Province 51h Postal Code 51i Country Date Employment Began mmddyyyy Was the beneficiary EVER in immigration proceedings Yes_8No_8 Removal Removal Rescission Rescission ExclusionDeportation ExclusionDeportation Other Judicial Proceedings Other Judicial Proceedings City or Town_8 55b State undefined_27 Form I130 021319_4 Page 7 of 12 Family Name_10 First Name_16 57c Middle Name Street Number_10 Apt_10 Apt_10 Ste_10 Ste_10 undefined_28 undefined_28 Flr_10 58c City or Town 58d Province 58e Postal Code 58f Country Street Number_11 Apt_11 Apt_11 Ste_11 Ste_11 undefined_29 undefined_29 Flr_11 59c City or Town 59d State 59e ZIP Code 59f Province 59g Postal Code 59h Country undefined_30 undefined_31 61a City or Town undefined_32 City or Town_9 Province_8 Country_8 Part 5 Other Information Have you EVER previously filed a petition for this Yes_9No_9 Family Name_11 First Name_17 Middle Name_7 City or Town_10 undefined_33 Result for example approved denied withdrawn If you are also submitting separate petitions for other relatives Family Name_12 First Name_18 Middle Name_8 Relationship_6 Form I130 021319_5 Page 8 of 12 Family Name_13 First Name_19 Middle Name_9 Relationship_7 I can read and understand English and I have read I can read and understand English and I have read The interpreter named in Part 7 read to me every The interpreter named in Part 7 read to me every At my request the preparer named in Part 8 At my request the preparer named in Part 8 undefined_34 undefined_35 Petitioners Daytime Telephone Number Petitioners Mobile Telephone Number if any Petitioners Email Address if any Form I130 021319_6 Page 9 of 12 Interpreters Family Name Last Name Interpreters Given Name First Name Interpreters Business or Organization Name if any Interpreters Mailing Address Apt_12 Apt_12 Street Number_12 Street Number_12 Flr_12 Flr_12 undefined_36 Ste_12 City or Town_11 ZIP Code 3e Postal Code_5 Country_9 Interpreters Daytime Telephone Number Interpreters Mobile Telephone Number if any Interpreters Email Address if any I certify under penalty of perjury that Preparers Family Name Last Name Preparers Given Name First Name Preparers Business or Organization Name if any Preparers Mailing Address Apt_13 Apt_13 Street Number_13 Street Number_13 Flr_13 Flr_13 undefined_37 Ste_13 City or Town_12 ZIP Code_2 3e_2 Postal Code_6 Country_10 Form I130 021319_7 Page 10 of 12 Preparers Daytime Telephone Number Preparers Mobile Telephone Number if any Preparers Email Address if any I am not an attorney or accredited representative but I am not an attorney or accredited representative but I am an attorney or accredited representative and my I am an attorney or accredited representative and my extends extends does not extend beyond the preparation does not extend beyond the preparation Form I130 021319_8 Page 11 of 12 Part 9 Additional Information Family Name_14 First Name_20 Middle Name_10 ANumber if any A Page Number Part Number 3c Item Number Page Number_2 Part Number_2 Item Number Page Number_3 Part Number_3 Item Number_2 Page Number_4 Part Number_4 Item Number_3 Page Number_5 Part Number_5 Item Number_4 Form I130 021319_9 Page 12 of 12 Δ