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Form I-90

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

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