Form I-90 - Application To Replace Permanent Resident Card
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5OMB No. 1615-0082; Expires 08/31/2012
I-90, Application to Replace
Department of Homeland Security
Permanent Resident Card
U.S. Citizenship and Immigration Services
FOR USCIS USE ONLY
Receipt
Action Block
Applicant
Class of Admission
Interviewed
START HERE - Type or print in black ink.
Part 1. Information About You
1. Your Current Legal Name (Your card will be issued in this name)
Family Name (Last Name)
Given Name (First Name)
Full Middle Name
2. Has your name legally changed since the issuance of your Permanent Resident Card?
(Proceed to Question 3)
(Skip to Question 4)
Yes
No
N/A - I never received my previous card. (Skip to Question 4)
3. Your name exactly as reflected on your Permanent Resident Card
Family Name (Last Name)
Full Middle Name
Given Name (First Name)
NOTE: Attach all evidence of your legal name change with this application.
4. U.S. Mailing Address
C/O Name:
Street Number and Name
Apt., Suite, or Floor
City
State
Zip Code + 4
5. U.S. Residence Address (if different from above)
Street Number and Name
Apt., Suite, or Floor
City
State
Zip Code + 4
Female
Male
7. Date of Birth (mm/dd/yyyy)
6. Gender
8. Country of Birth
9. City/Town/Village of Birth
11. A-Number
10. Social Security Number
12. Class of Admission
13. Date of Admission (mm/dd/yyyy)
Form I-90 (Rev. 11/23/10)Y
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