Application to Replace Permanent Residence Card - U.S. Homeland Security
Form I-90 06/30/15 Y
For
USCIS
Use
Only
Application to Replace Permanent Resident Card
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-90
OMB No. 1615-0082
Expires 10/31/2017
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
(Last Name)
3.b. Given Name
(First Name)
3.c.
4.
Middle 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.)
1.
Street Number
and Name
Mailing Address
6.a.
In Care Of Name
6.b.
6.c.
Apt. Flr.Ste.
6.d. City or Town
6.h.
Postal Code
6.i. Country
6.e.
State
6.f.
ZIP Code
Class of Admission
Applicant Interviewed
Action BlockReceipt
Date:
Remarks
Provide your name exactly as it is printed on your current
Permanent Resident Card.
NOTE: Attach all evidence of your legal name change with
this application.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c.
Middle Name
USCIS ELIS Account Number (if any)2.
►
6.g.
Province
Page 1 of 8
A-
Page 1/8
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