I-824 Sample Form
Part 1 : Information about you: (person filing This application)
Family Name: XYZ
Given Name: Salim
Company Or Organization Name: I left It Blank
Home Address : 101 India Street Apt # 410
City : Houston
State :texas
Zip: 10001
Country : USA
Mailing Address
Mailing Address :101 India Street Apt # 410
C/o (in CAre of) I left It Blank
City : Houston
State :Texas
Zip: 10001
Country : India
Day Time Phone Number : 718-000-0000
Country of Birth : India
Country Of Citizenship : India
DAte Of Birth : 1/01/1979
IRS Tax # (if Any): I left It Blank
A #: A12345678
U.S Social Security : 123-45-6789
Part 2: Reason for Request (Check One)
I am Requestion: (Check One Box)
Option
"C" : The CIS to notify a U.S Consulate that my status has been adjusted to permanant resident. Please notift the U.S Consulate at:
Mumbai, India
Part 3: Additional Information (Next Page)
1. Give the Following information about the orignal petition or application:
Type of Petition or Application (Form Name)
Type :I-485
Receipt Number ( On form i-797, Notice of Action)
Type :SRC-00-000-00000(Your 485 Receipt Number)
Filing Date of Petition or Application (mm/dd/yyyy)
Type : 11/29/2002 (Your Recipt Date of I-485)
Approval Date (mm/dd/yyyy)
Type: 11/24/2004 (Your Approval Date of I-485)
2. Give the following Information about the petitioner or applicant for the orignal petition or application.
Current/Most Recent Immigration Status:
Type : Permant Resident
Naturalization/Citizenship CErtificate Number
Type: N/A
3. Give the Following information about the principal benificary of the orignal petition or application.
Family Name: XYZ
Given Name: Salim
Date Of Birth: 1/01/1979
County Of Birth :India
A #: A12345678
Home Address : 101 India Street Apt # 410
City : Houston
State :texas
Zip: 10001
Country : USA
Mailing Address: I left It Blank (Dint even write N/A)
DAytime Phone: 718-000-0000
Part 4: Signature:
Sign Daytime Phone: 718-000-0000 Date 06/11/05
Rest Leave it Blank
Note: I did add an additional sheet along with this Form of my Brother Info for who my dad is doing the Following to Join
Type info like this on an Additional Sheet
Last Name: XYZ
Given Name : Sheizad
Date of Birth: 01/01/1985
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Filied i-824 On May 12th 2005 From Texas Service CEnter
Got I-824 Approval on May 31st 2005
Hope This Helps
If any one has any questions feel free to ask
Salim
