Immigration Adjustment of Status Form

IMMIGRATION ADJUSTMENT OF STATUS FORM

This Adjustment of Status Form (the Agreement) is entered into on this day by and between Applicant Name: (Applicant) and Petitioner Name: (Petitioner). Effective Date:

Recitals

WHEREAS, the Applicant seeks to adjust status to lawful permanent resident under applicable immigration statutes and regulations based upon the grounds identified below; and

WHEREAS, the Petitioner has submitted or will submit a petition or sponsorship supporting the Applicant's request for adjustment of status and will provide truthful documentation in support of that petition; and

WHEREAS, the parties desire to record their respective representations, responsibilities, notices, and certifications related to the adjustment of status application.

NOW, THEREFORE

In consideration of the mutual covenants set forth herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. Definitions

For purposes of this Agreement: "Adjustment Application" means the application and all supporting documentation filed to seek lawful permanent resident status on behalf of the Applicant; "Supporting Documentation" means evidence described in Section 3; "Applicable Law" means relevant federal statutes, regulations, and administrative guidance governing adjustment of status.

2. Applicant Representations and Warranties

The Applicant represents and warrants that all information provided in the Adjustment Application is true, complete, and accurate to the best of the Applicant's knowledge; that the Applicant is not subject to any grounds of inadmissibility that are not disclosed in this Agreement; and that the Applicant will promptly disclose any material change in circumstances relevant to eligibility for adjustment of status.

Applicant Date of Birth: Country of Birth: Alien Registration Number (A-Number), if any:

3. Documentation and Evidence

The Applicant shall submit the Adjustment Application with the following supporting documentation, as applicable: identity documents, birth certificate, passport biographic page, current and prior immigration records, marriage certificate or proof of qualifying relationship, employment authorization documents, medical examination report, and certified court dispositions for any arrests or convictions.

4. Fees and Payment Responsibility

The filing fees, biometric fees, and any associated governmental or professional fees required for preparation and filing of the Adjustment Application shall be borne as follows. Payment responsibility: Petitioner Applicant

5. Background Checks; Biometrics; Consent

The Applicant authorizes and consents to fingerprinting, photograph, and background checks by the appropriate authorities as required for adjudication. The Applicant also consents to disclosure of relevant records by third parties where required by law or regulation for the adjudication of the Adjustment Application.

6. Criminal History; Disclosure

The Applicant shall disclose any arrests, charges, or convictions and shall provide certified dispositions for each matter. Failure to disclose material criminal history may result in denial of the Adjustment Application and potential immigration consequences.

7. Immigration History

The Applicant shall list prior entries, departures, periods of authorized or unauthorized stay, and any prior removal, exclusion, or deportation proceedings. Provide copies of prior visas, I-94 records, and any prior approvals.

8. Confidentiality and Use of Information

The parties acknowledge that material submitted in connection with the Adjustment Application may be protected by privacy laws and regulations. Notwithstanding confidentiality obligations, the Petitioner may disclose information to counsel, designated family members, or governmental authorities where required or permitted by law.

9. Notices

All notices, requests, consents and other communications required or permitted under this Agreement shall be in writing and shall be delivered to the addresses below by hand, certified mail, or other carrier.

10. Amendments; Waiver; Counterparts

Any amendment to this Agreement must be in writing and signed by both parties. No waiver of any provision of this Agreement shall be effective unless in writing signed by the party waiving compliance. This Agreement may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one instrument.

11. Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the jurisdiction in which the primary place of filing is located, without regard to conflict of law principles.

12. Entire Agreement

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written, of the parties.

13. Severability

If any provision of this Agreement is held to be invalid, illegal or unenforceable, such provision shall be struck and the remaining provisions shall remain in full force and effect and shall be construed so as to best effectuate the original intent of the parties.

14. Certifications and Acknowledgements

The Applicant certifies under penalty of perjury that the information provided in connection with the Adjustment Application and in this Agreement is true and correct. The Applicant acknowledges that knowingly submitting false information may subject the Applicant to penalties provided by law, including denial of the application and removal proceedings.

15. Additional Statements

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