DS-230 Form Download pdf Application for Immigrant Visa and Alien Registration (Cuban Family Reunification Parole applications only)

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1. Family Name First Name Middle Name If deceased, give year of death Current Address 16. Father's Date of Birth (mm-dd-yyyy) 9. Marital Status Middle Name First Name 8. Gender 2. Other Names Used or Aliases (If married woman, give maiden name) PART I - BIOGRAPHIC DATA INSTRUCTIONS: Complete one copy of this form for yourself and each member of your family, regardless of age, who will immigrate with you. Please print or type your answers to all questions. Mark questions that are Not Applicable with "N/A" . If there is insufficient room on the form, answer on a separate sheet using the same numbers that appear on the form. Attach any additional sheets to this form. 3. Full Name in Native Alphabet (If Roman letters not used) THIS FORM MAY BE OBTAINED FREE AT CONSULAR OFFICES OF THE UNITED STATES OF AMERICA DS-230 Part I 07-2004 7. Nationality (If dual national, give both) OMB APPROVAL NO. 1405-0015 EXPIRES: 07/31/2007 ESTIMATED BURDEN: 1 HOUR* (See Page 2) Page 1 of 4 Address of spouse (If different from your own) : 13. Present Address (Street Address) (City or Town) (Province) (Country) 12. Your Present Occupation 10. Permanent address in the United States where you intend to live, if known (street address including zip code) . Include the name of a person who currently lives there. 11. Address in the United States where you want your Permanent Resident Card (Green Card) mailed, if different from address in item #10 (include the name of a person who currently lives there) . 4. Date of Birth (mm-dd-yyyy) 5. Age PREVIOUS EDITIONS OBSOLETE 14. Name of Spouse (Maiden or family name) 6. Place of Birth (City or town) (Province) (Country) Telephone number: U.S. Department of State APPLICATION FOR IMMIGRANT VISA AND ALIEN REGISTRATION Date (mm-dd-yyyy) and place of birth of spouse: Telephone number: Home Office Telephone number: Male Female Single (Never married) Married Widowed Divorced Separated Including my present marriage, I have been married times. Spouse's occupation: Date of marriage (mm-dd-yyyy) : 18. Mother's Date of Birth (mm-dd-yyyy) Place of Birth If deceased, give year of death Current Address First Name Middle Name 15. Father's Family Name Place of Birth First Name Middle Name 17. Mother's Family Name at Birth WARNING: Any false statement or concealment of a material fact may result in your permanent exclusion from the United States. This form (DS-230 PART I) is the first of two parts. This part, together with Form DS-230 PART II, constitutes the complete Application for Immigrant Visa and Alien Registration. *Public reporting burden for this collection of information is estimated to average 1 hour per response, including time require d for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. In accordance with 5 CFR 1320 5(b), persons are not required to respond to the collection of this information unless this form displays a currently valid OMB control number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520. DS-230 Part I NAME 19. List Names, Dates and Places of Birth, and Addresses of ALL Children. DATE (mm-dd-yyyy) ADDRESS (If different from your own) Page 2 of 4 PLACE OF BIRTH Privacy Act and Paperwork Reduction Act Statements 20. List below all places you have lived for at least six months since reaching the age of 16, including places in your countr y of nationality. Begin with your present residence. CITY OR TOWN PROVINCE COUNTRY FROM/TO (mm-yyyy) 21b. Person(s) named in 14 and 19 who will follow you to the United States at a later date. 21a. Person(s) named in 14 and 19 who will accompany you to the United States now. 22. List below all employment for the last ten years. EMPLOYER LOCATION JOB TITLE FROM/TO (mm-yyyy) In what occupation do you intend to work in the United States? 23. List below all educational institutions attended. SCHOOL AND LOCATION FROM/TO (mm-yyyy) COURSE OF STUDY DEGREE OR DIPLOMA Languages spoken or read: Professional associations to which you belong: 24. Previous Military Service 25. List dates of all previous visits to or residence in the United States. (If never, write "never") Give type of visa status, if known. Give DHS "A" number if any. Branch: Dates (mm-dd-yyyy) of Service: Rank/Position: Military Speciality/Occupation: LOCATION FROM/TO (mm-yyyy) TYPE OF VISA "A" NO. (If known) Yes No The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. The U.S. D epartment of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fai l to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. If you are issued an immigrant visa and are subsequently ad mitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, an d, if you so indicate, the Social Security Administration will use the information to issue you a social security number and card. SIGNATURE OF APPLICANT DATE (mm-dd-yyyy) U.S. Department of State APPLICATION FOR IMMIGRANT VISA AND ALIEN REGISTRATION PART II - SWORN STATEMENT EXCEPT AS OTHERWISE PROVIDED BY LAW, ALIENS WITHIN THE FOLLOWING CLASSIFICATIONS ARE INELIGIBLE TO RECEIVE A VISA. DO ANY OF THE FOLLOWING CLASSES APPLY TO YOU? DS-230 Part II *Public reporting burden for this collection of information is estimated to average 1 hour per response, including time require d for searching existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. In accordance with 5 CFR 1320 5(b), persons are not required to respond to the collection of this information unless this form displays a currently valid OMB control number. Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to: U.S. Department of State (A/RPS/DIR) Washington, DC 20520. 26. Family Name First Name Middle Name 27. Other Names Used or Aliases (If married woman, give maiden name) 28. Full Name in Native Alphabet (If Roman letters not used) 29. Name and Address of Petitioner Telephone number: United States laws governing the issuance of visas require each applicant to state whether or not he or she is a member of any class of individuals excluded from admission into the United States. The excludable classes are described below in general terms. You should read carefully the following list and answer YES or NO to each category. The answers you give will assist the consular officer to r each a decision on your eligibility to receive a visa. 30. Page 3 of 4 An alien who has a communicable disease of public health significance; who has failed to present documentation of having received vaccinations in accordance with U.S. law; who has or has had a physical or mental disorder that poses or is likely to pose a threat to the safety or welfare of the alien or others; or who is a drug abuser or addict. a. PREVIOUS EDITIONS OBSOLETE Privacy Act and Paperwork Reduction Act Statements The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. The U.S. D epartment of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fai l to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. If you are issued an immigrant visa and are subsequently ad mitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, an d, if you so indicate, the Social Security Administration will use the information to issue you a social security number and card. INSTRUCTIONS: Complete one copy of this form for yourself and each member of your family, regardless of age, who will immigrate with you. Please print or type your answers to all questions. Mark questions that are Not Applicable with "N/A" . If there is insufficient room on the form, answer on a separate sheet using the same numbers that appear on the form. Attach any additional sheets to this form. The fee should be paid in United States dollars or local currency equivalent, or by bank draft . WARNING: Any false statement or concealment of a material fact may result in your permanent exclusion from the United States. Even if you are issued an immigrant visa and are subsequently admitted to the United States, providing false information on th is form could be grounds for your prosecution and/or deportation. This form (DS-230 PART II), together with Form DS-230 PART I, constitutes the complete Application for Immigrant Visa and Alien Registration. OMB APPROVAL NO. 1405-0015 EXPIRES: 07/31/2007 ESTIMATED BURDEN: 1 HOUR* An alien convicted of, or who admits having committed, a crime involving moral turpitude or violation of any law relating to a controlled substance or who is the spouse, son or daughter of such a trafficker who knowingly has benefited from the trafficking activities in the past five years; who has been convicted of 2 or more offenses for which the aggregate sentences were 5 years or more; who is coming to the United States to engage in prostitution or commercialized vice or who has engaged in prostitution or procuring within the past 10 years; who is or has been an illicit trafficker in any controlled substance; who has committed a serious criminal offense in the United States and who has asserted immunity from prosecution; who, while serving as a foreign government official and within the previous 24-month period, was responsible for or directly carried out particularly severe violations of religious freedom; or whom the President has identified as a person who plays a significant role in a severe form of trafficking in persons, who otherwise has knowingly aided, abetted, assisted or colluded with such a trafficker in severe forms of trafficking in persons, or who is the spouse, son or daughter of such a trafficker who knowingly has benefited from the trafficking activities within the past five years. b. An alien who seeks to enter the United States to engage in espionage, sabotage, export control violations, terrorist activities, the overthrow of the Government of the United States or other unlawful activity; who is a member of or affiliated with the Communist or other totalitarian party; who participated in Nazi persecutions or genocide; who has engaged in genocide; or who is a member or representative of a terrorist organization as currently designated by the U.S. Secretary of State. c. An alien who failed to attend a hearing on deportation or inadmissibility within the last 5 years; who seeks or has sought a visa, entry into the United States, or any immigration benefit by fraud or misrepresentation; who knowingly assisted any other alien to enter or try to enter the United States in violation of law; who, after November 30, 1996, attended in student (F) visa status a U.S. public elementary school or who attended a U.S. public secondary school without reimbursing the school; or who is subject to a civil penalty under INA 274C. f. An alien who is likely to become a public charge. d. An alien who seeks to enter for the purpose of performing skilled or unskilled labor who has not been certified by the Secretary of Labor; who is a graduate of a foreign medical school seeking to perform medical services who has not passed the NBME exam or its equivalent; or who is a health care worker seeking to perform such work without a certificate from the CGFNS or from an equivalent approved independent credentialing organization. e. Yes No Yes No Yes No Yes No Yes No Yes No DO NOT WRITE BELOW THE FOLLOWING LINE The consular officer will assist you in answering item 35. DO NOT SIGN this form until instructed to do so by the consular officer 35. I claim to be: THIS FORM MAY BE OBTAINED FREE AT CONSULAR OFFICES OF THE UNITED STATES OF AMERICA DS-230 Part II Page 4 of 4 I understand that I am required to surrender my visa to the United States Immigration Officer at the place where I apply to ent er the United States, and that the possession of a visa does not entitle me to enter the United States if at that time I am found to be inadmissible under the imm igration laws. I understand that any willfully false or misleading statement or willful concealment of a material fact made by me herein may s ubject me to permanent exclusion from the United States and, if I am admitted to the United States, may subject me to criminal prosecution and/or deportation. I, the undersigned applicant for a United States immigrant visa, do solemnly swear (or affirm) that all statements which appear in this application, consisting of Form DS-230 Part I and Part II combined, have been made by me, including the answers to items 1 through 35 inclusive, and that they are true and complete to the best of my knowledge and belief. I do further swear (or affirm) that, if admitted into the United States, I will not engage in activities which would be prejudical to the public interest, or endanger the welfare, safety, or security of the United States; in activities which would be prohibited by the laws of the United States relating to espionage, sabotage, public disorder, or in other activities subversive to the national security; in any activity a purpose of which is the opposition to or the control, or overthrow of, the Government of the United States, by force, violence, or other unconstitutional means. I understand that completion of this form by persons required by law to register with the Selective Service System (males 18 th rough 25 years of age) constitutes such registration in accordance with the Military Selective Service Act. I understand all the foregoing statements, having asked for and obtained an explanation on every point which was not clear to m e. Signature of Applicant Subscribed and sworn to before me this day of at: Consular Officer An alien who is permanently ineligible for U.S. citizenship; or who departed the United States to evade military service in time of war. g. 31. Have you ever been charged, arrested or convicted of any offense or crime? (If answer is Yes, please explain) 32. Have you ever been refused admission to the United States at a port-of-entry? (If answer is Yes, please explain) Yes No i. j. k. l. h. 33a. Have you ever applied for a Social Security Number (SSN)? Yes Give the number Do you want the Social Security Administration to assign you an SSN (and issue a card) or issue you a new card (if you have an SSN)? You must answer "Yes" to this question and to the "Consent To Disclosure" in order to receive an SSN and/or card. 33b. CONSENT TO DISCLOSURE: I authorize disclosure of information from this form to the Department of Homeland Security (DHS), the Social Security Administration (SSA), such other U.S. Government agencies as may be required for the purpose of assigning me an SSN and issuing me a Social Security card, and I authorize the SSA to share my SSN with the INS. No 34. WERE YOU ASSISTED IN COMPLETING THIS APPLICATION? Yes No (If answer is Yes, give name and address of person assisting you, indicating whether relative, friend, travel agent, attorney, or other) A Family-Sponsored Immigrant An Employment-Based Immigrant A Diversity Immigrant A Special Category (Specify) I derive foreign state chargeability under Sec. 202(b) through my (Returning resident, Hong Kong, Tibetan, Private Legislation, etc.) Preference: Numerical limitation: (foreign state) An alien who is coming to the United States to practice polygamy; who withholds custody of a U.S. citizen child outside the United States from a person granted legal custody by a U.S. court or intentionally assists another person to do so; who has voted in the United States in violation of any law or regulation; or who renounced U.S. citizenship to avoid taxation. An alien who is a former exchange visitor who has not fulfilled the 2-year foreign residence requirement. An alien determined by the Attorney General to have knowingly made a frivolous application for asylum. An alien who has ordered, carried out or materially assisted in extrajudicial and political killings and other acts of violence against the Haitian people; who has directly or indirectly assisted or supported any of the groups in Colombia known as FARC, ELN, or AUC; who through abuse of a governmental or political position has converted for personal gain, confiscated or expropriated property in Cuba, a claim to which is owned by a national of the United States, has trafficked in such property or has been complicit in such conversion, has committed similar acts in another country, or is the spouse, minor child or agent of an alien who has committed such acts; who has been directly involved in the establishment or enforcement of population controls forcing a woman to undergo an abortion against her free choice or a man or a woman to undergo sterilization against his or her free choice; or who has disclosed or trafficked in confidential U.S. business information obtained in connection with U.S. participation in the Chemical Weapons Convention or is the spouse, minor child or agent of such a person. An alien who was previously ordered removed within the last 5 years or ordered removed a second time within the last 20 years; who was previously unlawfully present and ordered removed within the last 10 years or ordered removed a second time within the last 20 years; who was convicted of an aggravated felony and ordered removed; who was previously unlawfully present in the United States for more than 180 days but less than one year who voluntarily departed within the last 3 years; or who was unlawfully present for more than one year or an aggregate of one year within the last 10 years. Yes No Yes No No Yes Yes No Yes No Yes No Yes No Yes No The applicant's response does not limit or restrict the Government's ability to obtain his or her SSN, or other information on this form, for enforcement or other purposes as authorized by law. No Yes