Application To Determine Returning Resident Status

U.S. Department of State OMB APPROVAL NO.
1405-0091
EXPIRATION Date: 2/29/2020
APPLICATION TO DETERMINE ESTIMATED BURDEN: 30 MINUTES*
RETURNING RESIDENT STATUS

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:
(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.
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.
1. Family Name First 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
8. Previous Immigration Record

a. DHS "A" Number b. Immigration Category
c. Previous Immigrant Visa d. Adjustment of Status
Date of Issue (mm-dd-yyyy) Place of Issue Date of Adjustment of Status Place of Adjustment of
with DHS (IF ANY) (mm-dd-yyyy) Status with DHS (IF ANY)
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
9. Most Recent Departure from the United States

Date of Departure (mm-dd-yyyy) Destination
Reason
Privacy Act and Paperwork Reduction Act Statements
This information asked for on this form is requested pursuant to Sections 101 and 222 of the Immigration and Nationality Act. The U.S. Department of State uses the facts you provide on this form to
determine your eligibility for returning resident status. Individuals who fail to submit this form or who do not provide all the requested information may be denied returning resident status. Upon your
return to the United States in Immigrant status, the information collected will be protected from disclosure under the Privacy Act.
*Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary
documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB
control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov.
DS-117 Page 1 of 2
11-2013
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?
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.
Dates (mm-dd-yyyy)
Country
From To
13. Have you been employed outside of the United States since your most recent departure? Yes No
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. 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.
Signature of Applicant Date (mm-dd-yyyy)

DO NOT WRITE BELOW THIS SPACE - OFFICIAL USE ONLY
Approved 101(a)(27)(A) Disapproved

Reason
0 0 at
Type Name of Consular Officer Signature of Consular Officer Date (mm-dd-yyyy) Post
Reviewed Concur Do NOT Concur
0
Type Name of Reviewing Officer Signature of Reviewing Officer Date (mm-dd-yyyy)
DS-117 Page 2 of 2

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U.S. Department of State OMB APPROVAL NO.

RETURNING RESIDENT STATUS

1. Family Name First Name Middle Name

3. Current Home Address and Telephone Number

4. Place of Birth (City, Province, Country) 5. Date of Birth (mm-dd-yyyy)

8. Previous Immigration Record

9. Most Recent Departure from the United States

Name of Employer Address From (mm-dd-yyyy) To (mm-dd-yyyy)

14. I wish to return to the United States on or about

Signature of Applicant Date (mm-dd-yyyy)

Approved 101(a)(27)(A) Disapproved

Reviewed Concur Do NOT Concur

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