Application To Replace Permanent Resident Card
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2OMB No. 1615-0082; Expires 06/30/09
I-90, Application to Replace
Department of Homeland Security
Permanent Resident Card
U.S. Citizenship and Immigration Services
FOR USCIS USE ONLY
START HERE - Please type or print in black ink.
Receipt
Part 1. Information About You
Returned
Family Name
Given Name
Middle Initial
U.S. Mailing Address - C/O
Resubmitted
Street Number and Name
Apt. #
City
Reloc Sent
State
ZIP Code
Date of Birth(Month/
Country
Day/Year)
of Birth
Reloc Rec'd
Social
A #
Security #
Part 2. Application Type
1. My status is: (check one)
Applicant
a.
Permanent Resident - (Not a Commuter)
Interviewed
b.
Permanent Resident - (Commuter)
c.
Conditional Permanent Resident
Status as
Verified by
2. Reason for application: (check one)
I am a Permanent Resident or Conditional Permanent Resident and:
Class
Initials
a.
My card was lost, stolen or destroyed.
FD-258 forwarded on
b.
My authorized card was never received.
I-89 forwarded on
c.
My card is mutilated.
I-551 seen and returned
(Initials)
d.
My card was issued with incorrect information because of a USCIS administrative
Photocopy of I-551 verified
error. I have attached the incorrect card and evidence of the correct information.
(Initials)
e.
My name or other biographic information has changed since the card was issued.
Name
Date
I am a Permanent Resident and:
Sticker #
f.
My present card has an expiration date and it is expiring.
(ten-digit number)
g.
I have reached my 14th birthday since my card was issued.
Action Block
h. 1.
I have taken up Commuter status.
h. 2.
I was a Commuter and am now taking up residence in the U.S.
i.
My status has been automatically converted to permanent resident.
j.
I have an old edition of the card.
Part 3. Processing information.
Mother's First Name
Father's First Name
To Be Completed by
City of Residence where you applied for an
Consulate where Immigrant Visa was issued
Attorney or Representative, if any
Immigrant Visa or Adjustment of Status
or USCIS office where status was Adjusted
Fill in box if G-28 is attached to
represent the applicant
VOLAG#
City/Town/Village of Birth
Date of Admission as an immigrant or
Adjustment of Status
ATTY State License #
Form I-90 (Rev. 04/16/09)Y
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