Form I-90 06/30/15 Y
Application to Replace Permanent Resident Card
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0082
START HERE - Type or print in black ink.►
Part 1. Information About You
Alien Registration Number (A-Number)
Your Full Name
NOTE: Your card will be issued in this name.
3.a. Family Name
3.b. Given Name
Has your name legally changed since the issuance of your
Permanent Resident Card?
Yes (Proceed to Item Numbers 5.a. - 5.c.)
No (Proceed to Item Numbers 6.a. - 6.i.)
N/A - I never received my previous card.
(Proceed to Item Numbers 6.a. - 6.i.)
In Care Of Name
6.d. City or Town
Class of Admission
Provide your name exactly as it is printed on your current
Permanent Resident Card.
NOTE: Attach all evidence of your legal name change with
5.a. Family Name
5.b. Given Name
USCIS ELIS Account Number (if any)2.
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