Information about you:

Address (street number and name):

Mailing Address (if different than above):

Address (street number and name):

Country of birth:

Country of citizenship:

Alien registration number (#A):

Social Security Number (if any):

Conditional residence expires on (month/day/year):

Daytime phone # (area/country code):

Basis for petition:

1.  My conditional residence is based on my marriage to a U.S. citizen or permanent resident, and we are filing this petition together.
2.  I am a child who entered as a conditional permanent resident, and I am unable to be included in a joint petition to remove the conditional basis of an alien's permanent residence (Form I-751) filed by my parent(s).

OR
My conditional residence is based on my marriage to a U.S. citizen or permanent resident, but I am unable to file a joint petition and I request a waiver because: (check one)

3.  My spouse is deceased.
4.  I entered into the marriage in good faith but the marriage was terminated through divorce/annulment.
5.  I am a conditional resident spouse who entered a marriage in good faith, and during the marriage I was battered by or was the subject of extreme cruelty by my U.S. citizen or permanent resident spouse or parent.
6.  I am a conditional resident child who was battered or subjected to extreme cruelty by my U.S. citizen or conditional resident parent(s).
7.  The termination of my status and removal from the United States would result in an extreme hardship.

Additional information about you:

1. Other names used (including maiden name):
   
2. Date of marriage (month/day/year):
   
3. Place of marriage:
   
4. If your spouse is deceased, give the date of death (month/day/year):
   
5. Are you in removal, deportation or rescission proceedings?
   Yes No 
6. Was a fee paid to anyone other than an attorney in connection with this petition?
   Yes No
7. Since becoming a conditional resident, have you ever been arrested, cited, charged, indicted, convicted, fined or imprisoned for breaking or violating any law or ordinance (excluding traffic regulations), or committed any crime for which you were not arrested?
   Yes No
8. If you are married, is this a different marriage than the one through which conditional residence status was obtained?
   Yes No
9. Have you resided at any other address since you became a permanent resident? (if yes, attach a list of all addresses and dates.)
   Yes No
10. Is your spouse currently serving with or employed by the U.S. government and serving outside the United States?
    Yes No

If you answered 'yes' to any of the above, provide a detailed explanation on a separate sheet(s) of paper.

Information about the spouse or parent through whom you gained your conditional residence:

Address (street number and name):

Social Security # (if any):

A # (if any):

Information about your children. List all your children.

Names:

A Number (if any):

If in U.S. give address/immigration status:

Living with you?  Yes No