Page1 of i 360 .pdf

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Original filename: Page1 of i-360.pdf
Title: Form I-360
Author: USCIS

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VAWA
Petition for Amerasian, Widow(er), or Special Immigrant
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0020
Expires 03/31/2018
Action Block

Fee Stamp

For USCIS Use Only

USCIS
Form I-360

Returned
Resubmitted
Relocated

Received
Sent

Remarks:

To be completed by an
Attorney or Accredited
Representative (if any).

Petitioner/Applicant
Interviewed
Interviewed Beneficiary
Interviewed
I-485 Filed Concurrently
Bene "A" File Reviewed

Classification

Select this box if
Form G-28 or
G-28I is attached.

Attorney State Bar Number
(if applicable)

Consulate
Priority Date

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About Person or Organization Filing This Petition
NOTE: You must complete Part 1. as the petitioner if you are filing this petition on behalf of another person. If you are a Violence
Against Women Act (VAWA) self-petitioner or special immigrant juvenile, skip to Part 1., Item Number 7.
1.

Your Full Name
Family Name (Last Name)

Given Name (First Name)
John

John

2.

USCIS Online Account Number (if any)

3.


4.


6.

U.S. Social Security Number (if any)


Alien Registration Number (A-Number) (if any)

A-

Middle Name

5.

1

2

3

4

5

6

7 8

9

Individual IRS Tax Number (if any)


Mailing Address
In Care Of Name (if any)

Organization Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-360 12/23/16 N

Postal Code

ZIP Code

Country

Page 1 of 19


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