Form I-687 - Application For Status As A Temporary Resident Under Section 245a Of The Immigration And Nationality Act Page 3

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If you were admitted as a nonimmigrant prior to January 1, 1982, complete Numbers 21 through 29. If not, leave blank and
go to Number 30.
22. Country that Issued Passport
23. Location Where Visa Issued (City and Country)
21. Passport Number
24. Type of Visa Issued
25. Date Visa Issued
26. Authorized Stay in
27. Class of Admission (Student,
U.S.
(B-2, F-1, etc.)
(mm/dd/yyyy)
Expired (mm/dd/yyyy)
Visitor, etc.)
28. Did you violate your legal
29. Was your status violation known to the
status prior to January 1, 1982?
Government prior to January 1, 1982?
Yes If Yes, how was
No
Yes
No
your status violation
known to the
Government?
30. RESIDENCES IN THE UNITED STATES:
List all of your residences in the United States since your first entry, beginning with your present address. If you need more space
to complete, use a separate sheet of paper. Write your name and Alien Registration Number (A-Number), if any, at the top of each
sheet of paper and indicate on the sheet that the information refers to Number 30.
Number and Street Name
Apt. #
From (mm/yyyy)
To (mm/yyyy)
City
State
Zip Code
Number and Street Name
Apt. #
From (mm/yyyy)
To (mm/yyyy)
City
State
Zip Code
Number and Street Name
Apt. #
City
State
Zip Code
From (mm/yyyy)
To (mm/yyyy)
Number and Street Name
Apt. #
From (mm/yyyy)
To (mm/yyyy)
City
State
Zip Code
Number and Street Name
Apt. #
From (mm/yyyy)
To (mm/yyyy)
City
State
Zip Code
Number and Street Name
Apt. #
From (mm/yyyy)
To (mm/yyyy)
City
State
Zip Code
Number and Street Name
Apt. #
From (mm/yyyy)
To (mm/yyyy)
City
State
Zip Code
Form I-687 (11/23/10) Y Page 3

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