DS-117 Application pdf >> DS-117 Application pdf to Determine Returning Resident Status

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8. Previous Immigration Record First Name 1. Family Name Middle Name 2. Other Names Used, Aliases (If Married Woman, Give Maiden Name) 3. Current Home Address and Telephone Number 4. Place of Birth (City, Province, Country) 5. Date of Birth (mm-dd-yyyy) 6. Marital Status Married Single ( Never Married ) Widowed Divorced If married, information about spouse a. Name ( Last, First, MI ) b. Address c. Place of Birth d. Date of Birth ( mm-dd-yyyy ) e. U.S. Residence Status, if any ( U.S. Citizen, Legal Permanent Resident, Etc. ) f. Date of Marriage to You ( mm-dd-yyyy ) 7. List Below All Close Family Members in the United States (Continue on Separate Page if Necessary.) Full Name Relationship Resident Status Place of Residence a. DHS "A" Number b. Immigration Category c. Previous Immigrant Visa d. Adjustment of Status Date of Issue ( mm-dd-yyyy ) Date of Adjustment of Status with DHS ( IF ANY ) ( mm-dd-yyyy ) Place of Adjustment of Status with DHS ( IF ANY ) Place of Issue e. Initial Entry into the United as Lawful Permanent Resident f. Last Entry into the United States as Lawful Permanent Resident Date of Entry ( mm-dd-yyyy ) Port of Entry Date of Entry ( mm-dd-yyyy ) Port of Entry U.S. Department of State APPLICATION TO DETERMINE RETURNING RESIDENT STATUS OMB CONTROL NO.1405-0091 EXPIRATION Date: 05/31/2023 ESTIMATED BURDEN: 30 MINUTES* DS-117 10-2019 Page 1 of 3 INSTRUCTIONS This is an application for Special Immigrant Status under Section 101(a)(27)(A) of the Immigration and Nationality Act, for lawfully admitted permanent residents who are returning from a temporary visit abroad. To qualify you must submit with this application evidence that: Applicants must submit evidence with this application to support the above requirements, including proof of lawful permanent residence (Examples: Form I-151, I-551, Reentry Permit, etc.), dates of travel outside of the United States (Examples: airline tickets, passport stamps, etc.), proof of ties to the United States and intention to return (Examples: tax returns, and evidence of economic, family and social ties to the United States), and proof a protracted stay was for reasons beyond the applicant's control (Examples: medical incapacitation, employment with a U.S. company, accompanying a U.S. citizen spouse, etc.) All documents will be returned to you. 9. Most Recent Departure from the United States Date of Departure ( mm-dd-yyyy ) Destination Reason (1) You had the status of an alien lawfully admitted for permanent residence at the time of departure from the United States; (2) You departed from the United States with the intention of returning and you have not abandoned this intention; and (3) You are returning to the United States from a temporary visit abroad and, if the stay abroad was protracted, this was caused by reasons beyond your control and for which you are not responsible. 10. What continuing ties have you maintained with the United States? What efforts have you made to avoid abandoning your permanent resident status in the United States? 13. Have you been employed outside of the United States since your most recent departure? 11. Reasons for not returning to the United States until time of this application. 12. List below all periods that you have lived outside of the United States for six months or longer since your initial entry into the United States as a permanent resident. If "Yes" complete the following: Name of Employer Address From (mm-dd-yyyy) To (mm-dd-yyyy) 14. I wish to return to the United States on or about Date (mm-dd-yyyy) 15. By typing my name in the field below, I swear or affirm that all statements which appear on this application are true and complete to the best of my knowledge and belief. I understand that any false or misleading statement or willful concealment of a material fact may subject me to permanent exclusion from the United States. I understand that if this application for special immigrant status is approved, I must apply for an immigrant visa within six months from the date of approval. DO NOT WRITE BELOW THIS SPACE - OFFICIAL USE ONLY Approved 101(a)(27)(A) Reason Reviewed Concur Do NOT Concur Disapproved Dates (mm-dd-yyyy) From To Country Date (mm-dd-yyyy) Name of Applicant Type Name of Reviewing Officer at Post Date (mm-dd-yyyy) Date (mm-dd-yyyy) Will add electronic signature when converted to pdf Signature of Reviewing Officer Type Name of Consular Officer Will add electronic signature when converted to pdf Signature of Consular Officer Yes No DS-117 Page 2 of 3 AUTHORITIES: The information is sought pursuant to 8 U.S.C. § 1101 et seq, 8 U.S.C. §§ 1201-1202, and by regulations issued pursuant to 8 CFR 211.1 and 22 CFR 42.22. PURPOSE: The information solicited on this form will be used to determine your eligibility for returning resident status. ROUTINE USES: The information on this form maybe shared with federal, state, and local government agencies, members of Congress, and officials of foreign governments in accordance with certain approved routine uses. More information on the Routine Uses for the system can be found in the System of Records Notice State-39, Visa Records. DISCLOSURE: Providing this information is mandatory. Failure to provide the information requested on this form may result in the applicant's inability to receive returning resident status. Privacy Act Statements INA Section 222(f) provides that visa issuance and refusal records shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which certifies that the information contained in such records is needed in a case pending before the court. Confidentiality Statement Page 3 of 3 DS-117