A:_______________________
1. Complete Name (include maiden name and aliases):
________________________________________________________________________
________________________________________________________________________
2. Date of Birth: _________________________
Month/Day/Year
3. Place of Birth: (Specify Parish and Country):___________________________________________________
4. Date and Port (when and where) You First Entered the United States as a Permanent Resident:
________________________________________________________________________
5. Upon admission to the United States (U.S.) as a Permanent Resident, what was your address in the U.S.:
________________________________________________________________________
________________________________________________________________________6. Telephone numbers in Jamaica where you can be contacted: (Provide two contact numbers):
Contact Telephone #1:_______________________
Contact Telephone #2:_______________________
7. What is/was your relationship to the individual who Petitioned for your Permanent Resident status:
________________________________________________________________________
8. What was the method by which your Permanent Resident status was obtained:
9. Complete Names of your natural Mother and Father:
Mother:____________________________________Father________________________
10. Duration & Periods of absences outside of the United States since becoming a Permanent Resident of the U.S. (Covering no less than the last 12 months and starting with your recent trip to Jamaica now provide months/dates and duration of trips to Jamaica and state the purpose for each period of absence from the United States):
FROM TO DURATION PURPOSE OF TRIP
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
11. What is your current residential address in the United States: (Provide complete address, state whether you own or rent. If you live with relatives at this address specify who i.e., Mother, Father, Sister, Brother, Cousin, etc.):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
12. What year did you last file a U.S. Income Tax Return:___________________________________________
13. List all property/equities you currently own in the United States: (If you own a business please provide name, complete address and telephone number of the business)
________________________________________________________________________________________________________________________________________________
________________________________________________________________________
14. List all property/equities currently owned in Jamaica and all other countries except the United States: (If you own a business please provide name, complete address and telephone number of the business)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
15. List all jobs you have held in the United States since becoming a Permanent Resident of the U.S. (Starting with your current and/or most recent job and working back you must provide complete name of the employer/company, complete address of employer/company, telephone numbers of employer/company, and your starting and ending periods of employment):
EMPLOYER NAME, ADDRESS & TELEPHONE NUMBER START DATE END DATE
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
16. List all jobs you have held in Jamaica and/or countries other than the United States since becoming a Permanent Resident of the U.S. (Starting with your current and/or most recent job and working back you must provide complete name of the employer/company; complete address of employer/company; telephone numbers of employer/company, and your starting andending periods of employment):
EMPLOYER NAME, ADDRESS & TELEPHONE NUMBER START DATE END DATE
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
17. Provide complete names and addresses for your spouse, children and your parents:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
18. Have you previously filed an application for replacement of a lost, stolen, damaged or not yet received Permanent Resident Card? If yes, please give the date and location in the United States where the application was filed:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I swear and affirm under penalty of perjury that the information I have freely given on the Questionnaire and the attached "Record of Sworn State Form I-215W" is true and accurate to the best of my knowledge and belief. I understand that the information I have provided may be used against me in a criminal proceeding and that I may be subject to both Criminal and Civil Penalties for knowingly and willfully falsifying, concealing or misrepresenting material information and facts contained on this form.
NAME:_____________________________________________________
(Last/First/Middle)
SIGNATURE:_____________________ DATE:______________________
SIGNATURE OF PERSON PREPARING FORM IF OTHER THAN APPLICANT:
"I declare that I prepared the Questionnaire and the attached ’Record of Sworn Statement In Affidavit Form I-215W’ at the request of the person above and that is based on all information of which I have any knowledge."
PRINT COMPLETE NAME:___________________________________________________________
COMPLETE ADDRESS:_____________________________________________________________
RELATIONSHIP TO APPLICANT, IF ANY (BE SPECIFIC)__________________________________
SIGNATURE:_____________________________________________DATE:____________________
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Specific Functions
