Reloc Sent
Resubmitted
Department of Homeland Security
U.S. Citizenship and Immigration Services
For USCIS Use Only
Returned
Date
Date
Date
Date
Date
Date
Date
Date
Reloc Rec'd
Receipt
Action Block
Attorney or Representative, if any.
To Be Completed by
Fill in box if G-28 is attached to represent the applicant.
Remarks
Petitioner Interviewed on
Address: (Street number and name)
Date of Birth (mm/dd/yyyy)
Mailing Address, if different than above (Street number and name):
a.
b.
d.
c.
e.
f.
g.
My conditional residence is based on my marriage to a U.S. citizen or permanent resident, but I am unable to file a joint petition and I request a waiver because: (Check one)
Part 2. Basis for Petition (Check one)
Social Security # (If any)
Conditional Residence Expires on (mm/dd/yyyy)
Daytime Phone # (Area/Country codes)
OR
I-751, Petition to Remove
Conditions on Residence
A # (If any)
Other Names Used (including maiden name):
Date of Marriage (mm/dd/yyyy)
Have you resided at any other address since you became a permanent resident? (If yes, attach a list of all addresses and dates.)
Date of Birth (mm/dd/yyyy)
Social Security # (if any)
A# (if any)
Part 5. Information About Your Children-List all your children (Attach other sheet(s) if necessary)
Name (First/Middle/Last)
Date (mm/dd/yyyy)
Print Name
Date (mm/dd/yyyy)
NOTE: If you do not completely fill out this form or fail to submit any required documents listed in the instructions, you may not be found eligible for the requested benefit and this petition may be denied.
I declare that I prepared this petition at the request of the above person and it is based on all information of which I have knowledge.
Date (mm/dd/yyyy)
Daytime Phone Number (Area/Country codes)
If your spouse is deceased, give the date of death (mm/dd/yyyy)
Date of Birth (mm/dd/yyyy)
E-Mail Address
(If any)