No
1. Name (Family name in CAPS)
4. Date of Birth
5. Gender
7. Other Names Used (including maiden name)
8.Date and Place of Present Marriage (if married)
14b. Did you gain permanent resident status through marriage to a
U.S. citizen or lawful permanent resident?
Rescission
Date arrived
Yes
No
Yes Where
(State/Country)
1. Name (Family name in CAPS)
(First)
No
OMB #1615-0012; Expires 01/31/11
Form I-130 (Rev. 05/27/08)Y
2.Address (Number and Street)
3. Place of Birth (Town or City)
3. Place of Birth (Town or City)
9. U.S. Social Security Number (If any)
9. U.S. Social Security Number (If any)
15. Name and address of present employer (if any)
2. Address (Number and Street)
7. Other Names Used (including maiden name)
8. Date and Place of Present Marriage (if married)
Department of Homeland Security
U.S. Citizenship and Immigration Services
6. Marital Status
NOTE: Designation of a U.S. embassy or consulate outside the country of your relative's last residence does not guarantee acceptance for processing by that post. Acceptance is at the discretion of the designated embassy or consulate.
I declare that I prepared this document at the request of the person above and that it is based on all information of which I have any knowledge.
19. Your relative's address abroad. (Include street, city, province and country)
Form I-130 (Rev. 05/27/08)Y Page 2
21. If filing for your husband/wife, give last address at which you lived together. (Include street, city, province, if any, and country):
WARNING: USCIS investigates claimed relationships and verifies the validity of documents. USCIS seeks criminal prosecutions when family relationships are falsified to obtain visas.
PENALTIES: By law, you may be imprisoned for not more than five years or fined $250,000, or both, for entering into a marriage contract for the purpose of evading any provision of the immigration laws. In addition, you may be fined up to $10,000 and imprisoned for up to five years, or both, for knowingly and willfully falsifying or concealing a material fact or using any false document in submitting this petition.
YOUR CERTIFICATION: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Furthermore, I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to determine eligiblity for the benefit that I am seeking.