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APPLICATION TO DETERMINE EXPIRATION Date: …

8. Previous Immigration RecordFirst Name1. Family NameMiddle Name2. Other Names Used, Aliases (If Married Woman, Give Maiden Name)3. Current Home Address and Telephone Number4. Place of Birth (City, Province, Country)5. Date of Birth (mm-dd-yyyy)6. Marital StatusMarriedSingle (Never Married)WidowedDivorcedIf married, information about spousea. Name (Last, First, MI)b. Addressc. Place of Birthd. Date of Birth (mm-dd-yyyy)e. Residence status , if any ( Citizen, Legal Permanent resident , Etc.)

APPLICATION TO DETERMINE RETURNING RESIDENT STATUS OMB CONTROL NO.1405-0091 EXPIRATION Date: 05/31/2023 ESTIMATED BURDEN: 30 MINUTES* DS-117 10-2019 Page 1 of 3 INSTRUCTIONS This is an application for Special Immigrant Status under Section 101(a)(27)(A) of the Immigration and Nationality Act, for lawfully admitted permanent

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