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					                                  Weathersby, Howard & Kuck, LLC
                                  3350 Peachtree Road, NE, Suite 1600
                                        Atlanta, Georgia 30326

                      ADJUSTMENT OF STATUS QUESTIONNAIRE:
            PLEASE FILL IT OUT ELECTRONICALLY AND RETURN VIA: E-MAIL
Upon approval of your Immigrant Visa petition, you and your immediate family members, depending on immigrant visa
availability will be eligible to apply for adjustment of status to permanent resident with the Immigration and Naturalization
Service. In anticipation of this process, the following information is required to complete the necessary applications.

Last name:                                   First name:                                      Middle:
List all other names used:
Home Address:
Home telephone #:                                                 Home fax #:
Office Address,
including M/S#:
Office telephone #:                                               Office fax #:
Title of your position:
H. R. Contact:
H.R. Telephone # & e-mail:
Date of Birth:                                              Place of Birth:
                    (mo/day/yr)                                     (City, State, Country)
Social Security #:                                                      Nationality:
A# (if any):                                                            Male/Female:
Current Non-immigrant status:                                                   Expires on:
Have you ever before applied for permanent residence status? If so, give date and place of filing
    and final disposition:

1.   Information about your father:
     Last name
     First name
     Date, city and country of birth
     City and country of residence

2.   Information about your mother:
     Maiden name
     First name
     Date, city and country of birth
     City and country of residence

3.   Your residence for the last five years. List present address first.
     Street and Number                          City               State                        Country        From        To
                                                                                                               (mo./yr)    (mo./yr)
4.        Last residence outside the U.S. for more than one year.
          Street and Number                         City               State           Country     From       To
                                                                                                   (mo./yr)   (mo./yr)



5.        Employment for the last five years. List present employment first.
          Name of Employer, Street and Number City               State Country        Occupation   From        To
                                                                                                   (mo./yr)    (mo./yr)




6.        Last occupation abroad if not shown above.
          Name of Employer, Street and Number City                  State   Country   Occupation   From        To
                                                                                                   (mo./yr)    (mo./yr)



     7.     Date of last arrival:

 8.        No. on I-94 card:

 9.        Place of last entry in the U.S.:

10.        City and country where visa was issued:

11.        8 Digit Non-immigrant visa #:
           Date Visa was issued:
           Visa Expiration Date:

12.        Have you ever been in the U.S. on an F-1 student visa?:
              If yes, please list the dates you were in U.S. under F-1 visa status:




 13.        Have you ever before applied for employment authorization from INS?
            If yes, which INS office?
            Date(s) of application:
            Granted or denied?
            Please provide copies, front and back, of your work authorization card.

 14.        Information about your spouse:
            Last name (for wife, give maiden name)
            First name
            Date and place of marriage
       Applying with you?
       Current Status?

 15.   Your former husbands or wives (if none, so state)
       Last name (for wife, give maiden name)
       First name
       Date of birth
       City and country of birth
       Date and place of marriage
       Date and place of termination of marriage

 16.   List all of your children:                     Child #1                     Child #2                    Child #3
       Last name
       First name
       Middle name
       Male or Female?
       Date of birth
       Place of birth
       Country of Citizenship
       A# (if any)
       Social Security # or T.I.N.:
       Applying with you?

 17.   List your present or past membership in or affiliation with every political association, fund foundation,
       party, club, society, or similar group in the United States or in any other place since your 16th
       birthday. Include any military service in the past. If none, write “none.” Include the name of the
       organization, location, dates of membership from and to, and the nature of the organization . If
       additional space is needed, use separate paper.




QUESTIONS PERTAINING TO TAX ISSUES

Are you self-employed? Mark yes if you own and actively operate a business in which you share in the profits other than as    Yes   No
an investor?

Have you been in the United States for 183 days or more during any one of the three calendar years immediately preceding      Yes   No
the current calendar year? Mark “yes” if you received income paid by individuals or institutions located in the United
States. Income includes, but is not limited to, compensation for services provided by you, interest, dividends, rents, and
royalties.

Did you file a United States Individual Income Tax Return (Form 1040, 1040A, 1040EZ, or 1040NR) in any of the last            Yes   No
three years? If so for which tax year was the last return filed?

                                                                                                                   Tax year
 18.       Annual income:                                                      $
           Deposits in saving banks in the United States:                      $
           Value of personal property:                                         $
           Market value of stocks and bonds:                                   $
           Life insurance in the sum of:                                       $
           With cash surrender value of:                                       $
           Value of any real estate you own:                                   $
                 With mortgage or other encumbrances thereon
                 amounting to:                                                 $
           Address of such real estate:


 19.       List all persons who depend upon you for support wholly or partially.
           Name of person:
           Wholly or partially dependent?
           Age:
           Relationship to you:


 20.       List all the persons for whom you have submitted affidavit(s) of support . If none, state “None.”




 21.       List all the persons for whom you have ever personally sponsored for an immigrant visa.




      COMPLETE ONLY IF THERE IS THE POSSIBILITY OF INTERNATIONAL TRAVEL OVER THE
                                   NEXT SIX MONTHS.

 22.       Date of intended departure:
 23.       Expected length of trip:
 24.       Purpose of trip:

THE FOLLOWING QUESTIONS WILL APPEAR ON THE ADJUSTMENT OF
STATUS APPLICATION. PLEASE CHECK YES OR NO.
1.        Have you ever, in or outside the U.S:

     a)   knowingly committed any crime of moral turpitude or a drug-related offense for which you have not been arrested?         Yes   No

 b)       been arrested, cited, charged, indicted, fined or imprisoned for breaking or violation any law or ordinance, excluding   Yes   No
          traffic violations?

     c)   been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?               Yes   No

 d)       exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.?                                   Yes   No
2.        Have you received public assistance in the U.S. from any source, including the U.S. government or any state, country,        Yes   No
          city, or municipality (other than emergency medical treatment), or are you likely to receive public assistance in the
          future?

3.        Have you ever:

     a)   Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in    Yes   No
          the future?

 b)       Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?                                Yes   No

     c)   Knowingly encouraged, induced, assisted, or aided any alien to try to enter the U.S. illegally?                              Yes   No

 d)       Illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of   Yes   No
          any controlled substances?

5.        Do you intend to engage in the U.S. in:

     a)   Espionage?                                                                                                                   Yes   No

 b)       any activity of purpose of which is opposition to. or the control or overthrow of, the Government of the United States,      Yes   No
          by force, violence or other unlawful means?

     c)   any activity to violate or evade any law prohibiting the export from the United States of goods, technology or               Yes   No
          sensitive information?

6.        Have you ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?          Yes   No


          Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of                  Yes   No
7.        Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order,
          incite, assist or otherwise participate in the persecution of any person because of race, religion, national origin or
          political opinion?

8.        Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of       Yes   No
          any person because of race, religion, nationality, ethnic origin, or political opinion?

9.        Have you ever been deported from the U.S. or removed from the U.S. at government expense, excluded within the                Yes   No
          past year, or are now in exclusion or deportation proceedings?

10.       Are you under a final order of civil penalty for violating section 274C of the                                               Yes   No
          immigration act for use of fraudulent documents, or have you, by fraud or willful
          misrepresentation of a material fact, ever sought to procure, or procured, a visa,
          other documentation, entry into the U.S. or any other immigration benefit?
11.       Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?                                               Yes   No

12.       Have you ever been a J nonimmigrant exchange visitor who was subject to the 2 year foreign residence requirement             Yes   No
          and not yet complied with that requirement or obtained a waiver?

13.       Are you now withholding custody of a U.S. Citizen child outside the U.S. from a person granted custody of the child?         Yes   No

14.       Do you plan to practice polygamy in the U.S.?                                                                                Yes   No
PLEASE SUBMIT THE FOLLOWING DOCUMENTS WITH THE QUESTIONNAIRE:

 COMPLETE COPY OF PASSPORT (ALL FAMILY MEMBERS)
 COPIES OF ALL FORMS I-797s, I-20s, IAP-66s, EAD cards (ALL FAMILY
 MEMBERS)
 COPY OF I-94 CARD (ALL FAMILY MEMBERS)
 COPY OF BIRTH CERTIFICATE, WITH TRANSLATION (IF
 APPLICABLE). This must be the "long form,” with names of BOTH parents
 of each applicant. Please provide “long form” which includes your name and
 both parent’s names. (ALL FAMILY MEMBERS)
 COPY OF MARRIAGE CERTIFICATE & DIVORCE DECREE, WITH
 TRANSLATION (IF APPLICABLE)
 COPIES OF U.S. TAX RETURNS FOR PAST 3 YEARS, or YEARS YOU
 HAVE BEEN IN THE U.S., WHICHEVER IS LESS
 LETTER FROM YOUR BANK VERIFYING YOU HAVE A CHECKING
 AND/OR SAVINGS ACCOUNT, WHEN THE ACCOUNT WAS OPENED
 AND THAT YOUR ACCOUNT IS IN GOOD STANDING
IF YOU ARE MARRIED, THE FOLLOWING QUESTIONS ARE TO BE
ANSWERED BY YOUR SPOUSE:
Last name:                                    First name:                                      Middle:
List all other names used:
Home Address:
Home telephone #:                                                  Home fax #:

Date of Birth:                                               Place of Birth:
                   (month/day/year)                                            (City, State, Country)
Social Security #:                                                       Nationality:
A# (if any):                                                             Male/Female:
Current Non-immigrant status:                                                   Expires on:
Have you ever before applied for permanent residence status? If so, give date and place of filing
   and final disposition:

 2   Information about your father:
5.
     Last name
     First name
     Date, city and country of birth
     City and country of residence

 2   Information about your mother:
6.
     Maiden name
     First name
     Date, city and country of birth
     City and country of residence

 2   Your residence for the last five years. List present address first.
7.
     Street and Number                          City                State            Country       From       To
                                                                                                   (mo./yr)   (mo./yr)




 2   Last residence outside the U.S. for more than one year.
8.
     Street and Number                          City                State            Country       From       To
                                                                                                   (mo./yr)   (mo./yr)



2    Your employment for the last five years. List present employment first. (If none, please say “None”)
9.
       Name of Employer, Street and Number      City            State    Country   Occupation    From        To
                                                                                                 (mo./yr)    (mo./yr)




 3     Last occupation abroad if not shown above. (If none, please say “None”)
0.
       Name of Employer, Street and Number       City            State   Country   Occupation     From       To
                                                                                                  (mo./yr)   (mo./yr)

 31.     Date of last arrival:

32.     No. on I-94 card:

33.     Place of last entry in the U.S.:

34.     City and country where visa was issued:

35.     8 Digit Non-immigrant visa #:
        Date Visa was issued:
        Visa Expiration Date:

36.     Have they ever been in the U.S. on an F-1 student visa?:
           If yes, please list the dates you were in U.S. under F-1 visa status:




 37.     Have they ever before applied for employment authorization from INS?
         If yes, which INS office?
         Date(s) of application:
         Granted or denied?
         Please provide copies, front and back, of your work authorization card.

 38.     If applicable, former husbands/ wives (if none, so state)
         Last name (for wife, give maiden name)
         First name
         Date of birth
         City and country of birth
         Date and place of marriage
         Date and place of termination of marriage

 39.     List your present or past membership in or affiliation with every political association, fund foundation,
         party, club, society, or similar group in the United States or in any other place since your 16th
         birthday. Include any military service in the past. If none, write “none.” Include the name of the
      organization, location, dates of membership from and to, and the nature of the organization . If
      additional space is needed, use separate paper.




40.   Did you file a U.S. Individual Income Tax Return in any of the last three years (even if joint)?
      If yes, for which tax year was the last return filed?

41.   If spouse is employed, their annual income:                   $

COMPLETE ONLY IF THERE IS THE POSSIBILITY OF INTERNATIONAL TRAVEL
                   OVER THE NEXT SIX MONTHS.
42.   Date of intended departure:
43.   Expected length of trip:
44.   Purpose of trip:
THE FOLLOWING QUESTIONS WILL APPEAR ON THE ADJUSTMENT OF STATUS
APPLICATION. PLEASE CHECK YES OR NO .

1.        Have you ever, in or outside the U.S:

     a)   knowingly committed any crime of moral turpitude or a drug-related offense for which they have not been arrested?            Yes   No

 b)       been arrested, cited, charged, indicted, fined or imprisoned for breaking or violation any law or ordinance, excluding       Yes   No
          traffic violations?

     c)   been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency or similar action?                   Yes   No

 d)       exercised diplomatic immunity to avoid prosecution for a criminal offense in the U.S.?                                       Yes   No

2.        Have you received public assistance in the U.S. from any source, including the U.S. government or any state, country,        Yes   No
          city, or municipality (other than emergency medical treatment), or are they likely to receive public assistance in the
          future?

3.        Have you ever:

     a)   Within the past 10 years been a prostitute or procured anyone for prostitution, or intend to engage in such activities in    Yes   No
          the future?

 b)       Engaged in any unlawful commercialized vice, including, but not limited to, illegal gambling?                                Yes   No

     c)   Knowingly encouraged, induced, assisted, or aided any alien to try to enter the U.S. illegally?                              Yes   No

 d)       Illicitly trafficked in any controlled substance, or knowingly assisted, abetted or colluded in the illicit trafficking of   Yes   No
          any controlled substances?

4.        Have you ever engaged in, conspired to engaging, or do they intend to engage in, or have they ever solicited                 Yes   No
          membership or funds for, or have they through any means ever assisted or provided any type of material support to,
          any person or organization that has been engaged or conspired to engage, in sabotage, kidnapping, political
          assassination, hijacking, or any other form of terrorist activity

5.        Do you intend to engage in the U.S. in:

     a)   Espionage?                                                                                                                   Yes   No

 b)       any activity of purpose of which is opposition to. or the control or overthrow of, the Government of the United States,      Yes   No
          by force, violence or other unlawful means?

     c)   any activity to violate or evade any law prohibiting the export from the United States of goods, technology or               Yes   No
          sensitive information?

6.        Have they ever been a member of, or in any way affiliated with, the Communist Party or any other totalitarian party?         Yes   No

7.        Did you, during the period March 23, 1933 to May 8, 1945, in association with either the Nazi Government of                  Yes   No
          Germany or any organization or government associated or allied with the Nazi Government of Germany, ever order,
          incite, assist or otherwise participate in the persecution of any person because of race, religion, national origin or
          political opinion?

8.        Have you ever engaged in genocide, or otherwise ordered, incited, assisted or otherwise participated in the killing of       Yes   No
          any person because of race, religion, nationality, ethnic origin, or political opinion?
9.    Have you ever been deported from the U.S. or removed from the U.S. at government expense, excluded within the          Yes   No
      past year, or are now in exclusion or deportation proceedings?

10.   Are you under a final order of civil penalty for violating section 274C of the                                         Yes   No
      immigration act for use of fraudulent documents, or have they, by fraud or willful
      misrepresentation of a material fact, ever sought to procure, or procured, a visa,
      other documentation, entry into the U.S. or any other immigration benefit?
11.   Have you ever left the U.S. to avoid being drafted into the U.S. Armed Forces?                                         Yes   No

12.   Have you ever been a J nonimmigrant exchange visitor who was subject to the 2 year foreign residence requirement       Yes   No
      and not yet complied with that requirement or obtained a waiver?

13.   Are you now withholding custody of a U.S. Citizen child outside the U.S. from a person granted custody of the child?   Yes   No

14.   Do you plan to practice polygamy in the U.S.?                                                                          Yes   No

				
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