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Part 1. Information About You
Department of Homeland Security
U.S. Citizenship and Immigration Services
For USCIS Use Only
Attorney or Representative, if any
To Be Completed by
Fill in box if Form G-28 is
attached to represent the
ATTY State License #
Form I-751 (Rev. 01/12/11) Y
Family Name (Last Name)Given Name (First Name)Full Middle Name
C/O: (In care of)
Address: (Street Number and Name)
Date of Birth (mm/dd/yyyy)Country of Birth
C/O: (In care of)
Mailing Address, if different than above (Street Number and Name):
My conditional residence is based on my marriage to a U.S. citizen or permanent resident,
and we are filing this petition together.
My spouse is deceased.
I am a child who entered as a conditional permanent resident, and I am unable to be included
in a joint petition filed by my parent(s).
OMB No. 1615-0038; Expires 01/31/2013
I am a conditional resident spouse who entered a marriage in good faith, and during the
marriage I was battered by or was the subject of extreme cruelty by my U.S. citizen or
permanent resident spouse or parent.
I entered into the marriage in good faith, but the marriage was terminated through divorce or
My conditional residence is based on my marriage to a U.S. citizen or permanent resident, I am
unable to file a joint petition, and I request a waiver because: (Check one)
Part 2. Basis for Petition(Check one)
Country of Citizenship
Alien Registration Number (A-Number) Social Security # (if any)
Conditional Residence Expires on (mm/dd/yyyy)
Daytime Phone # (Area/Country Code)
The termination of my status and removal from the United States would result in an extreme
I am a conditional resident child who was battered by or subjected to extreme cruelty by my
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