i-130

Naturalization. Give certificate number and date and place of issuance.

(First)

1. Name (Family name in CAPS)

(Middle)

(Town or City)

(State/Country)

(State/Country)

4. Date of Birth

Gender

8.Date and Place of Present Marriage (if married)

Yes. Give certificate number, date and place of issuance.

16. Has your relative ever been under immigration proceedings?

14b. Did you gain permanent resident status through marriage to a Married Single Date arrived

Date and place of admission for or adjustment to lawful permanent residence and class of admission.

RESUBMITTED

RELOCATED: Rec'd

Sent

COMPLETED: Appv'd

Denied

INITIAL RECEIPT

Yes Where

When (Town or City)

(State/Country)(Zip/Postal Code)1. Name (Family name in CAPS) (First)

(Middle)You are the petitioner. Your relative is the beneficiary.

10. Alien Registration Number 12. Date(s) Marriage(s) Ended

Male 10. Alien Registration Number

He or she arrived as a:

(visitor, student, stowaway, without inspection, etc.)Birth in the U.S.

No

Ret'd

OMB #1615-0012; Expires 01/31/2011

Form I-130 (Rev. 06/14/10)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)11. Name(s) of Prior Husband(s)/Wive(s)

11. Name(s) of Prior Husband(s)/Wive(s)

13. If you are a U.S. citizen, complete the following:14. If you are a lawful permanent resident alien, complete the following:

Date authorized stay expired, or will expire, as shown on Form I-94 or I-95

15. Name and address of present employer (if any)Date this employment began

12. Date(s) Marriage(s) Ended

2. Address (Number and Street)(Apt. No.)

(Apt. No.)

(Zip/Postal Code)(State/Country)

8. Date and Place of Present Marriage (if married) No

22. Complete the information below if your relative is in the United States and will apply for adjustment of status.

C. Information about your alien relative (continued)

(Name)

(Date of Birth)

(Country of Birth)

(Relationship)

Phone Number (if any)

(Name)Address (Include street, city, province and country):From:

To:

1. If separate petitions are also being submitted for other relatives, give names of each and relationship.

(City)(Country 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.

D. Other information

Yes Date

Phone Number F. Signature of person preparing this form, if other than the petitioner.

Print Name Date

G-28 ID or VOLAG Number, if any.

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.(State)

Your relative is in the United States and will apply for adjustment of status to that of a lawful permanent resident at the USCIS office in:

19. Your relative's address abroad. (Include street, city, province and country)(Street Address)

E. Signature of petitioner.

2. Have you ever before filed a petition for this or any other alien?

If "Yes," give name, place and date of filing and result.

Address

Signature

(City)

(State)

Form I-130 (Rev. 06/14/10)Y Page 2

( )

17. List husband/wife and all children of your relative.

18. Address in the United States where your relative intends to live.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.

(Town or City)

20. If your relative's native alphabet is other than Roman letters, write his or her name and foreign address in the native alphabet.

If your relative is not eligible for adjustment of status, he or she will apply for a visa abroad at the American consular post in:

No

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.