Application to Determine Returning Resident Status
The application to determine returning resident status can be found at this location DS-0117 (state.gov). The form for Special Immigrant Status under Section 101(a)(27)(A) of the Immigration and Nationality Act requests the following information:
Family Name. First Name. Middle Name.
Other names – aliases – married name
Current address and phone number
Place of Birth – City, Province, Country
Date of Birth
Marital Status. This item requests the identifying information for the spouse: Name, address, place of birth, US residence status (US Citizen, Legal Permanent Resident, Etc.), and the Date of Marriage
You’ll need to identify all close family members. This information includes their name, relationship, resident status, and place of residence.
Previous immigration record of the applicant. This box requests that the applicant identifies for check off the following:
DHS “A” Number
Prior immigration visa. Date of Issue. Place of Issue
Adjustment of status. You’ll need to provide the date of the issue and the place of the issue.
Most recent departure for the United States. Identify the date of departure, your destination, and the reason for the departure
The applicant will need to list the continuing ties that you have maintained in the US. You’ll also need to state the efforts you have made to avoid abandoning your permanent residence in the US.
The applicant will need to list the reasons for not returning to the United States until the time of this application.
You’ll need to list all periods that you’ve lived outside the US for six months or longer since your initial entry into the US as a permanent resident. This box includes giving information about the dates you were not in the US and the country you lived in.
This box wants to know if you have been employed outside the US since your most recent departure. If so, you’ll need to provide the name of the employer, the address of the employer, and the appropriate dates.
Indicate here the date you wish to return to the United States
You’ll then need to sign and date that you “swear or affirm that all statements which appear on this application are true and correct to the best of my knowledge and belief. I understand that any false or misleading statement or willful concealment of a material fact may subject me to permanent exclusion from the United States. I understand that if this application for special immigrant status is approved, I must apply for an immigrant visa within six months from the date of approval.
The remaining information will be completed by the consular officer.