Application to Replace Permanent Resident Card
Department of Homeland Security
U.S. Citizenship and Immigration Services
Applicant Interviewed

USCIS
Form I-90
OMB No. 1615-0082
Expires 10/31/2017

Receipt

Action Block

Date:
Class of Admission
For
USCIS
UseOnly Remarks► START HERE - Type or print in black ink.

Part 1. Information About You
1.

Alien Registration Number (A-Number)

A2.

USCIS ELIS Account Number (if any)►Your Full Name

Provide your name exactly as it is printed on your current
Permanent Resident Card.
NOTE: Attach all evidence of your legal name change withthis application.
5.a. Family Name
(Last Name)
5.b. Given Name(First Name)
5.c. Middle Name

NOTE: Your card will be issued in this name.
3.a. Family Name
(Last Name)
3.b. Given Name(First Name)
3.c. Middle Name
4.

Has your name legally changed since the issuance of your
Permanent Resident Card?
Yes (Proceed to Item Numbers 5.a. - 5.c.)
No (Proceed to Item Numbers 6.a. - 6.i.)
N/A - I never received my previous card.
(Proceed to Item Numbers 6.a. - 6.i.)

Mailing Address
6.a. In Care Of Name6.b. Street Numberand Name
6.c.

Apt.

Ste.

Flr.

6.f.

ZIP Code

6.d. City or Town
6.e. State
6.g. Province
6.h. Postal Code
6.i.

Form I-90 06/30/15 YCountry

Page 1 of 8

Part 1. Information About You (continued)

Part 2. Application Type

Physical Address

NOTE: If your conditional permanent resident status (forexample: CR1, CR2, CF1, CF2) is expiring within the next 90
days, then do not file this application. (See the What is thePurpose of This Application section of the Form I-90
Instructions for further information.)

Provide this information only if different than mailing address.
7.a. Street Numberand Name
7.b.

Apt.

Ste.

Flr.

7.c. City or Town
7.d. State
7.f.

My status is (Select only one box):
1.a.

Lawful Permanent Resident (Proceed to Section A.)

1.b.

Permanent Resident - In Commuter Status(Proceed to Section A.)

1.c.

Conditional Permanent Resident(Proceed to Section B.)

7.e. ZIP CodeProvince

7.g. Postal CodeReason for Application (Select only one box)

7.h. Country

Section A. (To be used only by a lawful permanent resident ora permanent resident in commuter status.)

Additional Information2.a.

My previous card has been lost, stolen, or destroyed.

2.b.

My previous card was issued but never received.

8.

GenderMaleFemale

2.c.

My existing card has been mutilated.

9.

Date of Birth(mm/dd/yyyy) ►

2.d.

10.

City/Town/Village of Birth

My existing card has incorrect data because ofDepartment of Homeland Security (DHS) error.
(Attach your existing card with incorrect data alongwith this application.)

11.

Country of Birth2.e.

My name or other biographic information has beenlegally changed since issuance of my existing card.

2.f.

My existing card has already expired or will expire
within six months.

2.g1.

I have reached my 14th birthday and am registering
as required. My existing card will expire AFTER my16th birthday. (See NOTE below for additional
information.)

2.g2.

I have reached my 14th birthday and am registering
as required. My existing card will expire BEFORE
my 16th birthday. (See NOTE below for additional
information.)

Mother's Name
Given Name(First Name)
Father's Name

12.

13.
14.

15.

16.

Given Name(First Name)Class of Admission

Date of Admission(mm/dd/yyyy) ►U.S. Social Security Number (if any)
►Form I-90 06/30/15 YNOTE: If you are filing this application before your14th birthday, or more than 30 days after your 14thbirthday, you must select reason 2.j. However, if
your card has expired, you must select reason 2.f.

Page 2 of 8

Part 2. Application Type (continued)
2.h1.

I am a permanent resident who is taking up commuter
status.

2.h1.1.

My Port-of-Entry (POE) into the United States will be:

3.a1. Port-of-Entry where admitted to the United States:
City or Town and State

4.

City or Town and State

Have you ever been in exclusion, deportation, or removal
proceedings or ordered removed from the United States?
Yes

2.h2.

I am a commuter who is taking up actual residence inthe United States.

2.i.

I have been automatically converted to lawfulpermanent resident status.

2.j.

I have a prior edition of the Alien Registration Card,or I am applying to replace my current Permanent
Resident Card for a reason that is not specified above.

5.

Since you were granted permanent residence, have you
ever filed Form I-407, Abandonment by Alien of Status as
Lawful Permanent Resident, or otherwise been determined
to have abandoned your status?
YesNo

NOTE: If you answered "Yes" to Item Numbers 4. or 5.
above, provide a detailed explanation in the space provided inPart 8. Additional Information.

Section B. (To be used only by a conditional permanent resident.)

Biographic Information

3.a.

My previous card has been lost, stolen, or destroyed.

6.

3.b.

My previous card was issued but never received.

3.c.

My existing card has been mutilated.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

3.d.

My existing card has incorrect data because of DHS
error. (Attach your existing permanent resident cardwith incorrect data along with this application.)

7.

Race (Select all applicable boxes)
White

3.e.

No

Asian
Black or African American

My name or other biographic information has legallychanged since the issuance of my existing card.

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Part 3. Processing Information
1.

2.

Location where you applied for an immigrant visa oradjustment of status:

8.

Height9.

Weight10.

Eye Color (Select only one box)

Location where your immigrant visa was issued or USCIS
office where you were granted adjustment of status:

Complete Item Numbers 3.a. and 3.a1. if you entered theUnited States with an immigrant visa. (If you were granted
adjustment of status, proceed to Item Number 4.)
3.a. Destination in the United States at time of admission

Form I-90 06/30/15 Y

11.

Feet

InchesPoundsBlack
GrayBlue

Brown

Green

Hazel

MaroonPink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
SandyBlackGrayWhiteBlondRed
Unknown/OtherPage 3 of 8

Part 4. Accommodations for Individuals withDisabilities and/or Impairments (Read theinformation in the Form I-90 Instructions before
completing this part.)
NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
1.

Are you requesting an accommodation because of yourdisabilities and/or impairments?
Yes
NoIf you answered "Yes," select any applicable boxes:
1.a.

I am deaf or hard of hearing and request thefollowing accommodation (If you are requesting asign-language interpreter, indicate for which
language (for example, American Sign Language)):

1.b.

I am blind or have low vision and request thefollowing accommodation:

1.c.

I have another type of disability and/or impairment(Describe the nature of your disability and/orimpairment and the accommodation you arerequesting):

Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,Certification, and Signature
NOTE: Read the information on penalties in the Form I-90
Instructions before completing this part. You must file Form
I-90 while in the United States.

Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.

I can read and understand English, and have read andunderstand every question and instruction on thisapplication, as well as my answer to every question.
I have read and understand the Acknowledgement ofAppointment at USCIS Application Support
Center.

1.b.

The interpreter named in Part 6. has read to me everyquestion and instruction on this application, as well as
my answer to every question, in,a language in which I am fluent. I understand everyquestion and instruction on this application astranslated to me by my interpreter, and have provided
complete, true, and correct responses in the languageindicated above. The interpreter named Part 6. has
also read the Acknowledgement of Appointment at
USCIS Application Support Center to me, in thelanguage in which I am fluent, and I understand thisApplication Support Center (ASC)
Acknowledgement as read to me by my interpreter.

2.

I have requested the services of and consented to,isis not an attorney or accredited
whorepresentative, preparing this application for me.
This person who assisted me in preparing myapplication has reviewed the Acknowledgement ofAppointment at USCIS Application Support
Center with me, and I understand the ASC
Acknowledgement.

Form I-90 06/30/15 YPage 4 of 8

Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature (continued)
Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Acknowledgement of Appointment at USCIS
Application Support CenterI,,understand that the purpose of a USCIS ASC appointment isfor me to provide fingerprints, photograph, and/or signatureand to re-affirm that all of the information in my applicationis complete, true, and correct and was provided by me. I
understand that I will sign my name to the following
declaration which USCIS will display to me at the time I
provide my fingerprints, photograph, and/or signature during
my ASC appointment:
By signing here, I declare under penalty of perjury that I
have reviewed and understand my application, petition, orrequest as identified by the receipt number displayed on thescreen above, and all supporting documents, applications,petitions, or requests filed with my application, petition, orrequest that I (or my attorney or accredited representative)
filed with USCIS, and that all of the information in thesematerials is complete, true, and correct.

Applicant's Certification
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any informationfrom any and all of my records that USCIS may need todetermine my eligibility for the immigration benefit I seek.
I furthermore authorize release of information contained in thisapplication, in supporting documents, and in my USCIS records
to other entities and persons where necessary for theadministration of U.S. immigration laws.
I certify, under penalty of perjury, that the information in myapplication and any document submitted with my application
were provided by me and are complete, true, and correct.

Applicant's Signature
6.a. Applicant's Signature

6.b. Date of Signature: (mm/dd/yyyy) ►Part 6. Interpreter's Contact Information,Certification, and Signature
Interpreter's Full Name
Provide the following information concerning the interpreter.
1.a. Interpreter's Family Name (Last Name)

1.b. Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

I also understand that when I sign my name, provide myfingerprints, and am photographed at the USCIS ASC, I will be
re-affirming that I willingly submit this application; I havereviewed the contents of this application; all of the information
in my application and all supporting documents submitted with
my application were provided by me and are complete, true, andcorrect; and if I was assisted in completing this application, theperson assisting me also reviewed this Acknowledgement ofAppointment at USCIS Application Support Center with me.

Form I-90 06/30/15 YPage 5 of 8

Part 6. Interpreter's Contact Information,Certification, and Signature (continued)
Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. ZIP CodeProvince

3.g. Postal Code3.h. Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

The applicant has informed me that he or she understands every
instruction and question on the application, as well as the answer
to every question, and the applicant verified the accuracy ofevery answer; andThe applicant has also informed me that he or she understands
the ASC Acknowledgement and that by appearing for a USCISASC biometric services appointment and providing his or her
fingerprints, photographs, and/or signature, he or she isre-affirming that the contents of this application and all
supporting documentation are complete, true, and correct.

Interpreter's Signature
6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy) ►Part 7. Contact Information, Statement,Certification, and Signature of the Person
Preparing This Application, If Other Than theApplicant
Preparer's Full Name
Provide the following information concerning the preparer.
1.a. Preparer's Family Name (Last Name)

Interpreter's Certification
I certify that:I am fluent in English andwhichis the same language provided in Part 5., Item Number 1.b.;

1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

I have read to this applicant every question and instruction on
this application, as well as the answer to every question, in thelanguage provided in Part 5., in Item Number 1.b.; andI have read the Acknowledgement of Appointment at USCIS
Application Support Center to the applicant in the samelanguage provided in Part 5., in Item Number 1.b.

Form I-90 06/30/15 YPage 6 of 8

Part 7. Contact Information, Statement,Certification, and Signature of the Person
Preparing This Application, If Other Than theApplicant (continued)

7.a.

I am not an attorney or accredited representative but
have prepared this application on behalf of theapplicant and with the applicant's consent.

Preparer's Mailing Address

7.b.

I am an attorney or accredited representative and myrepresentation of the applicant in this casedoes not extend beyond theextends
preparation of this application.

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. ZIP CodePreparer's Statement

NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this application, you must submit acompleted Form G-28, Notice of Attorney orAccredited Representative, with this application.

Province

Preparer's Certification
3.g. Postal Code
3.h. Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number (if any)

6.

Preparer's Email Address (if any)

By my signature, I certify, swear or affirm, under penalty ofperjury, that I prepared this application on behalf of, at therequest of, and with the express consent of, the applicant. I
completed this application based only on responses theapplicant provided to me. After completing the application, I
reviewed it and all of the applicant's responses with theapplicant, who agreed with every answer on the application. If
the applicant supplied additional information concerning aquestion on the application, I recorded it on the application. I
have also read the Acknowledgement of Appointment atUSCIS Application Support Center to the applicant and theapplicant has informed me that he or she understands the ASC
Acknowledgement.

Preparer's Signature
8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy) ►NOTE: If you do not completely fill out this application or failto submit required documents listed in the instructions, yourapplication may be denied.

Form I-90 06/30/15 Y

Page 7 of 8

4.a. Page Number

Part 8. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. Include your name and A-Number (if any) at the
top of each sheet; indicate the Page Number, Part Number,and Item Number to which your answer refers; and sign anddate each sheet.

4.b. Part Number

4.c. Item Number

5.b. Part Number

5.c. Item Number

4.d.

Your Full Name
1.a. Family Name
(Last Name)
1.b. Given Name(First Name)
1.c. Middle Name
2.

A-Number (if any)

5.a. Page Number

A3.a. Page Number

3.b. Part Number

3.c. Item Number

5.d.

3.d.

Form I-90 06/30/15 Y

Page 8 of 8