Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status
[I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status]
IMPORTANT: Information on this site may be outdated. For up-to-date instructions and filing fees check always with the USCIS site:
http://www.uscis.gov/forms
Purpose of Form :
This form is used to provide statistical data to the Department of Health and Human Services regarding refugees or asylees who wish to adjust to immigrant status in the United States.
Number of Pages :
2
Edition Date :
5/19/06. Versions other than the 5/19/06 edition are not acceptable.
Where to File :
The Immigration Officer assisting you with this form will submit it to:
Data Unit, Office of Refugee Resettlement
Department of Health and Human Services
370 L’Enfant Promenade S.W. (6th Floor)
Washington, DC 20447
Filing Fee :
$0.00
Special Instructions :
(NA)
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No: 1615-0070; Expires 06/30/07
I-643, Health and Human Services Statistical Data for Refugee/Asylee Adjusting Status
Instructions
(To the Applicant – Type or print plainly in black ink.)
Purpose of This Form.
Refugees and asylees should submit this Form I-643 when filing an application for adjustment of status.
This form should be fully completed by a refugee or asylee, age 16 years or older. Representatives of applicants younger than 16 should only complete Blocks 1 and 2.
Although the information requested on Form I-643 will not affect the adjudication of the adjustment application, your application will not be considered as completely filed unless you submit this form. The data collected on this form will be used by U.S. Department of Health and Human Services to compile and analyze statistics relating to refugees and asylees. The form will not be retained by U.S. Citizenship and Immigration Services (USCIS). NOTE: USCIS is comprised of the offices of the former Immigration and Naturalization Service (INS).
Reporting Burden. An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. This collection of information is estimated to average from 10 minutesper response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of thiscollection of information, including suggestions for reducing this burden, to:
U.S. Citizenship and Immigration Services, Regulatory Management Division 111 Massachusetts Avenue, N.W. Washington, DC 20529, OMB No. 1615-0070.
Do not mail your completed application to this address.
Privacy Act Notice. Our legal right to ask for this information is in 8 U.S.C. 1184. All the information provided on this form, including addresses, are protected by the Privacy Act and the Freedom of Information Act. This information will not be released in any form whatsoever to a third party, other than another government agency, who requests it without a court order or without your written consent, or in the case of a child, the written consent of the parent or legal guardian who filed the form on the child’s behalf.
How to Complete the Form.
Block 1:
Enter your name, the date on which you are completing this form and your Alien Registration Number on the first line. On the second line, enter your country of birth and your country of citizenship. On the third line, enter your native language, your date of birth and your telephonenumber. Enter your current address on the fourth line.
Block 2:
Fill in your three (3) most recent cities and states of residence in the United States in order, starting with your current place of residence. If you have not lived in three (3) different cities since you entered the United States, write “none” on as many lines as appropriate.
Block 3:
Show the total number of people living in your household and the number currently employed. Fill in the first line for yourself, then list any other persons who live in your household. If more than five (5) persons live with you, attach a separate page listing the others and provide the information requested.
Block 4:
Enter the information about all jobs you have held since coming to the United States, starting with your current or most recent job. Under “Job Title” write the term that best describes the work you do, such as “machine operator,” “nurse” or “chemist.” If you have not worked at all since coming to the United States, write “none.” At the bottom of the block enter your major occupation before coming to the United States. If you did not work before coming to the United States, enter “none.”
Block 5:
Check the block or blocks that best describe your education before coming to the United States. Also, check the block or blocks that best describe how and where you have learned English.
Block 6:
If you have had any training or education in the United States, check the block or blocks that best describe your training and enter your major course of study. If you have not had any training in the United States, enter “none.”
Block 7:
Check the block that best describes your ability to use English.
Block 8:
Check as many types of public assistance as you have received or someone has received on your behalf. Indicate the month and year the assistance started and stopped. If you are still receiving assistance, write “present” in the block headed “To (mm/yyyy),” noting month/year.
Instructions to USCIS Officer
After this form has been completed, forward it directly to the address as shown below: (If you are mailing a small number of forms, they may be folded so that the address shows through a #20 window envelope.)
Data Unit, Office of Refugee Resettlement Department Of Health And Human Services 370 L’Enfant Promenade S. W., (6th Floor) Washington, D. C. 20447