Preview
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Petition for or Special Immigrant USCIS
Amerasian, Widow(er),
Form I-360
Department of Homeland Security OMB No. 1615-0020
U.S. Citizenship and Immigration Services Expires 04/30/2024
For USCf$ Use Fee Stamp Action Block
y
Returned
Resubmitted
Received
Relocated
Sent
Remarks: O Petitioner/Applicant Classification
Interviewed
O Interviewed Beneficiary
Interviewed
Consulate
O I-485 Filed Concurrently
"A" Date
O Bene File Reviewed Priority
Select this box if Attorney State Bar Number Attorney or Accredited Representative
Iobecompleted by an
Form G-28 or (if applicable) USCIS Online Account Number (if any)
\ t1o rnes or Accredited
-28I is attached. 4 8 6 O 6 1 O 3 9
RepreseItative (if any). 2742773 O O 9
º START HERE - Type or print in black ink.
Part 1. Information About Person or Organization Filing This Petition
NOTE: You must complete Part 1. as the petitioner if you are filing this petition on behalf of another person. If you are a Violence
Against Women Act (VAWA) self-petitioner or special immigrant juvenile, skip to Part 1., Item Number 7.
1. Your Full Name
Family Name (Last Name) Given Name (First Name) Middle Name
LAZCANO RAMIREZ FERNANDO
2. USCIS Online Account Number (if any) 3. U.S. Social Security Number (if any)
4. Alien Registration Number (A-Number) (if ady) 5. Individual IRS Tax Number (if any)
º A- º
6. Mailing Address
In Care Of Name (if any)
KOFI O AMANKWAA ESQ
Organization Name (if applicable)
LAW OFFICE
Street Number and Name Apt. Ste. Fir. Number
881 GERARD AVE 700
City or Town State ZIP Code
BRONX NY 10452
Province Postal Code Country
USA
Form I-360 Edition 07/15/22 Page 1 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Part J. information About Person or Organization Filing This Petition (continued)
7. Alternate and/or Safe Mailing Address
If you are a VAWA self-petitioning spouse, child, parent, or a special immigrant juvenile and do not want U.S. Citizenship and
Immigration Services (USCIS) to send notices about this petition to your home, you may provide an alternate and/or safe mailing
address.
In Care Of Name (if any)
SAME
Street Number and Name Apt. Ste. Fir. Number
O¡¡
City or Town State ZIP Code
Province Postal Code Country
Part 2. Classification Requested
Select only one box.
1. A. ¡ Amerasian
B. ¡ Widow(er) of a U.S. citizen
C. ¡ Special Immigrant Juvenile
D. ¡ Special Immigrant Religious Worker
(1) Will the beneficiary be working as a minister? O Yes ¡ No
E. ¡ Special Immigrant based on employment with the Panama Canal Company, Canal Zone Government, or U.S.
Government in the Canal Zone
F. ¡ Special Immigrant Physician
G. ¡ Special Immigrant G-4 International Organization Employee or Family Member or NATO-6 Employee or Family
Member
H. ¡ Special Immigrant Armed Forces Member
L ¡ Self-Petitioning Spouse of Abusive U.S. citizen or Lawful Permanent Resident
J. ¡ Self-Petitioning Child of Abusive U.S. citizen or Lawful Permanent Resident
K. ¡ VAWA Self-Petitioning Parent of a U.S. citizen son or daughter
L. ¡ Special Immigrant Afghanistan or Iraq National who worked with the U.S. Armed Forces as a translator
M. ¡ Special Immigrant Iraq National who was employed by or on behalf of the U.S. Government
N. ¡ Special Immigrant Afghanistan National who was employed by or on behalf of the U.S. Government or the
International Security Assistance Force (ISAF) in Afghanistan
O. ¡ Broadcasters
P. ¡ Other
Provide the name of the classification below.
Form I-360 Edition 07/15/22 d Page 2 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
"beneficiary" "self-petitioner"
NOTE: On this petition, the or means the person for whom this petition is being filed. If you provided
an alternate and/or safe mailing address above, you must also complete Part 3.
1. Your Full Name
Family Name (Last Name) Given Name (First Name) Middle Name
LAZCANO RAMIREZ FERNANDO
2. Mailing Address
In Care Of Name (if any)
KOFI O AMANKWAA ESQ
Street Number and Name Apt. Ste. Fir. Number
881 GERARD AVE 700
City or Town State ZIP Code
BRONX NY 10452
Province Postal Code Country
USA
3. Date of Birth (mm/dd/yyyy) 4. Country of Birth
MEXICO
5. U.S. Social Security Number (if any) 6. A-Num ber (if any)
º º A-
7. MaritalStatus ¡ Single ¡ Married ¡ Divorced ¡ Widowed
"none,"
Complete Item Numbers 8. - 15. if this person is in the United States. If an item number is not applicable or the answer is leave
the space blank. Provide information below for the passport or other document used at the time of last arrival to the United States.
8. Date of Last Arrival (mm/dd/yyyy) 9. Form I-94 Number or I-95 Crewman's Landing Permit
09/16/2005 º
10. Passport Number 11. Travel Document Number
12. Country of Issuance for Passport or Travel Document 13. Expiration Date for Passport or Travel Document
MEXICO (mm/dd/yyyy) 03/11/2031
14. Current Nonimmigrant Status 15. Date current status expired, or will expim as shown on
NO STATUS Form I-94 or I-95 (mm/dd/yyyy)
I. If the person listed in Part 3. is outside the U S., is meligible to adjust status in the U.S., or does not wish to adjust status m the
U.S., provide the following information about the U.S. Consulate at which the person prefers to apply for an immigrant visa.
U.S. Consulate
A. City or Town
B. Country
Form 1-360 Edition 07/15/22 . Page3ofl9
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
2. If a U.S. address was provided in Part 3., type or print the person's foreign address below. If he or she does not maintain a
foreign address, list the city or town and country of last foreign residence. If his or her native alphabet does not use Roman
letters, type or print his or her name and foreign address in the native alphabet.
A. Your Full Name
Family Name (Last Name) Given Name (First Name) Middle Name
LAZCANO RAMIREZ FERNANDO
B. Mailing Address
Street Number and Name Apt. Ste. Fir. Number
City or Town
TULANCINGO
Province Postal Code Country
HIDALGO NEXICO
3. Gender of the beneficiary: E Male ¡ Female
4. A. Are you filing any other petitions or applications with this one? ® Yes ¡ No
"Yes"
B. If you answered to Item A. in Item Number 4., how many? 3
"Yes"
If you answer to Item Numbers 5. - 6., provide an explanation in the space provided in Part 15. Additional Information.
5. Is the beneficiary in removal proceedings? ¡ Yes ® No
6. Has the beneficiary ever worked in the U.S. without permission? (If you are applying for a special
E Yes ¡ No
immigrant juvenile status, you are not required to answer this itemnumber.)
7. Is an application for adjustment of status attached to this petition? ® Yes ¡ No
NOTE: Depending on the classification you seek, you can either file this petition for another person or for yourself. On this petition,
"beneficiary" "self-petitioner"
the or means the person for whom this petition is being filed, whether that person is yourself or another
person.
1. If you are filing as a self-petitioning spouse, have any of your children filed separate self-petitions? ¡ Yes ¡ No
2. Person 1
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
¡ Spouse ¡ Child
Form I-360 Edition 07/15/22 Page 4 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Part 5. Information About the Spouse and Children of the Benef;ciary (coptinued)
3. Person 2
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
¡ Child
4. Person 3
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
¡ Child
5. Person 4
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
O Child
6. Person 5
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
. .
º A-
¡ Child
7. Person 6
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
¡ Child
Form I-360 Edition 07/15/22 Page 5 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Part 5. information Âbout the Spouse and Children of the Beneficiary (continued)
8. Person 7
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
¡ Child
9. Person 8
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
¡ Child
10. Person 9
Family Name (Last Name) Given Name (First Name) Middle Name
Date of Birth (mm/dd/yyyy) Country of Birth
Relationship A-Number (if any)
º A-
¡ Child
Part 6. Complete Only If Filing for an Amerasian
Information About the Mother of the Amerasian
1. Mother's Full Name
Family Name (Last Name) Given Name (First Name) Middle Name
2. A. Is the mother still alive? ¡ Unknown ¡ Yes ¡ No
"Yes"
B. If you answered to Item A. in Item Number 2., provide her address below.
In Care OfName (if any)
Street Number and Name Apt. Ste. Fir. Number
¡¡O
City or Town State ZIP Code
Province Postal Code Country
Form I-360 Edition 07/15/22 Page 6 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Part 6. Complete duly If Filing for an Amerasian (continued)
"No"
C. If you answered to Item A. in Item Number 2., provide her date of death (mm/dd/yyyy).
In formation 4bout the Fatherofthe Amerasian
If possible, attach a notarized statement from the father regarding parentage. If there is a question you cannot fully answer in the
space provided on this petition, use the space provided in Part 15. Additional Information.
3. Father's Full Name
Family Name (Last Name) Given Name (First Name) Middle Name
4. Date of Birth (mm/dd/yyyy) 5. Country of Birth
6. A. Is the father still alive? ¡ Unknown ¡ Yes ¡ No
"Yes"
B. If you answered to Item A. in Item Number 6., provide his address below.
In Care Of Name (if any)
Street Number and Name Apt. Ste. Flr. Number
City or Town State ZIP Code
Province Postal Code Country
"No"
C. If you answered to Item A. in Item Number 6., provide his date of death (mm/dd/yyyy).
D. Daytime Telephone Number (if any) E. Work Telephone Number (if any)
At the time the Amerasian was conceived:
7. A. The father was in the military (indicate branch of service below).
¡ Army ¡ Air Force ¡ Navy ¡ Marine Corps ¡ Coast Guard
B. Provide the father's service number:
C. ¡ The father was not in the military and was not a civilian employed abroad. (Attach a full explanation of the
circumstances.)
l'art 7. Complete Only If filing as a Widow/Widower
1. Full Name of U.S. Citizen Husband or Wife Who Died
Family Name (Last Name) Given Name (First Name) Middle Name
2. Date of Birth (mm/dd/yyyy) 3. Country of Birth 4. Date of Death (mm/dd/yyyy)
Form I-360 Edition 07/15/22 I Page 7 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Part 7. Complete Only If Filing as a Widow/Widower (continued)
5. At time of death, your spouse was a (Select only one):
A. O U.S. citizen born in the United States
B. ¡ U.S. citizen born abroad to U.S. citizen parents
C. ¡ U.S. citizen through naturalization
Provide A-Number (if any) º A-
(1)
D. ¡ Other (Explain)
6. How many times have you been married?
7. How many times was your spouse married?
8. A. When did you and your spouse get married (mm/dd/yyyy)?
B. Where did you and your spouse get married?
9. A. Did you remarry after the death of your spouse? ¡ Yes ¡ No
"Yes"
B. If you answered to Item A. in Item Number 9., provide the date that you remarried (mm/dd/yyyy).
10. If you are filing as a widow(er), were you legally separated at the time of the U.S. citizen's death? ¡ Yes ¡ No
"Yes"
NOTE: If you answered to Item Number 10., provide an explanation in the space provided in Part 15. Additional
Information.
Part 8. Complete Only If Filing for a Special Immigrant Juvenile
Information ÄImut che Juvenile
1. List any other names used:
A. Family Name (Last Name) Given Name (First Name) Middle Name
B. Family Name (Last Name) Given Name (First Name) Middle Name
"No"
Answer the following questions regarding the person for whom the petition is being filed. If you answer to Item A. in Item
Number 2., provide an explanation in the space provided in Part 15. Additional Information.
2. A. Have you been declared dependent on a juvenile court in the United States OR has ajuvenile court ¡ Yes ¡ No
legally committed you to, or placed you under the custody of, an agency, department of a state, or an
individual or entity?
B. Provide the name of the state agency, department, or court-appointed organization or individual with which you are placed
below.
C. Are you currently under the jurisdiction of the juvenile court that made your placement or custody ¡ Yes ¡ No
determination identified in Item B. in Item Number 2. above?
Form I-360 Edition 07/15/22 Page 8 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Part S. Complete Only If Filing for a Special linmigrant Jmenile (coDünued)
"Yes"
3. A. If you answered to Item C. in Item Number 2. above, are you currently residing in your
court-ordered placement?
B. "No"
If you answered to Item C. in Item Number 2. above, select your reason below.
¡ You were adopted or placed in a permanent guardianship or another permanent living arrangement (other than
reunification with the abusive parents).
¡ You aged-out of the juvenile courts jurisdiction and the order was terminated based on age.
"Other,"
¡ Other. (If you selected provide an explanation in the space provided in Part 15. Additional Information.)
4. A. A juvenile court has determined that reunification with ¡ one or ¡ both of my parents is not viable due to:
¡ Abuse ¡ Neglect ¡ Abandonment
¡ Similar basis under state law (specify):
"one"
B. If you selected in Item A. in Item Number 4., provide the name of that parent below.
5. Has it been determined in judicial or administrative proceedings that it would not be in your best interest O Yes ¡ No
to be returned to your or your parents country of citizenship or nationality or last habitual residence?
6. A. Are you currently or were you previously in the custody of the U.S. Department of Health and ¡ Yes ¡ No
Human Services (HHS)?
"Yes"
B. If you answered to Item A. in Item Number 6., and you are in HHS custody, did the juvenile ¡ Yes ¡ No
court order determine or alter your custody status or placement?
Part 9. Complete Only If Filing a Special Immigrant lleligious Worker Petition
Prospective Employer Attestation
1. Provide the following information about the prospective employer.
A. Number of members of the prospective employer's organization
B. Number of employees working at the same location where the beneficiary will be employed
C. Number of aliens holding special immigrant or nonimmigrant religious worker status who are currently
employed or were employed within the past five years
D. Number of Special Immigrant Religious Worker (Form I-360) and Nonimmigrant Religious Worker
(Form I-129) petitions submitted by the prospective employer within the past five years
E. Number of Special Immigrant Religious Worker (Form I-360) petitions submitted by the beneficiary
during the last five years
2. Has the beneficiary or have any of the beneficiary's dependent family members previously been admitted O Yes ¡ No
to the United States for a period of stay in the Religious Worker (R) classification during the last five
years?
"Yes"
If you answered to Item 2., provide the beneficiary's
Number and any dependent family member's prior periods of stay in
the R classification in the United States during the last five years. Be sure to provide only those periods when the beneficiary
and/or family members were actually in the United States in the R classification. Provide the beneficiary's information in Item
Number 3. below. For dependent family members, use the space provided in Part 15. Additional Information.
NOTE: Submit photocopies of Form I-94 Arrival-Departure Record, Form I-797 (Notice of Action), and/or other USCIS
documents identifying these periods of stay in the R classification. If you need extra space to complete this section, use the
space provided in Part 15. Additional Information.
Form I-360 Edition 07/15/22 Page 9 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
3. Beneficiary
Family Name (Last Name) Given Name (First Name) Middle Name
Period of Stay
From (mm/dd/yyyy) To (mm/dd/yyyy)
4. Provide a summary of the type of responsibilities of those employees, other than the beneficiary, who work at the same location
where the beneficiary will be employed. If you need extra space to complete this section, use the space provided in Part 15.
Additional Information.
Position
Summary of the Type of Responsibilities for That Position
5. Describe the relationship, if any, between the religious organization in the United States and the organization abroad of which
the beneficiary is a member.
6. Provide the following information about the prospective employment. If you need extra space to complete this section, use the
space provided in Part 15. Additional Information.
A. Title of position offered
B. The beneficiary will be working (select one of the following):
¡ As a minister
¡ In a religious vocation
¡ In a religious occupation
C. Detailed description of the beneficiary's proposed daily duties
D. Description of the beneficiary's qualifications for the position offered
E. Description of the proposed salaried and/or non-salaried compensation
F. Provide the specific addresses or locations where the beneficiary will be working
Company Name
Street Number and Name Apt. Ste. Fir. Number
o¡¡
City or Town State ZIP Code
Province Postal Code Country
Form I-360 Edition 07/15/22 Page 10 of 19
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E
NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024
Part 9. Complete Only lfFiling a Special Im migrant Religious €orker Petition (continued
7.- "No" 7.-
Answer Item Numbers 13. about the prospective employer. If you answer for Item Numbers 13., provide an explanation
in the space provided in Part 15. Additional Information.
7. The prospective employer is a bona fide non-profit religious organization or a bona fide organization that ¡ Yes ¡ No
is affiliated with the religious denomination and is tax exempt as described in section 501(c)(3) of the
Internal Revenue Code of 1986, subsequent amendment, or equivalent sections of prior enactments of the
Internal Revenue Code. If the prospective employer is affiliated with the religious denomination,
complete the Religious Denomination Certification included in this petition.
"Yes,"
If you answered select the applicable box and attach the appropriate documentation to the petition.
A. ¡ A currently valid determination letter from the Internal Revenue Service (IRS) establishing that the
Preview
FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Petition for or Special Immigrant USCIS Amerasian, Widow(er), Form I-360 Department of Homeland Security OMB No. 1615-0020 U.S. Citizenship and Immigration Services Expires 04/30/2024 For USCf$ Use Fee Stamp Action Block y Returned Resubmitted Received Relocated Sent Remarks: O Petitioner/Applicant Classification Interviewed O Interviewed Beneficiary Interviewed Consulate O I-485 Filed Concurrently "A" Date O Bene File Reviewed Priority Select this box if Attorney State Bar Number Attorney or Accredited Representative Iobecompleted by an Form G-28 or (if applicable) USCIS Online Account Number (if any) \ t1o rnes or Accredited -28I is attached. 4 8 6 O 6 1 O 3 9 RepreseItative (if any). 2742773 O O 9 º START HERE - Type or print in black ink. Part 1. Information About Person or Organization Filing This Petition NOTE: You must complete Part 1. as the petitioner if you are filing this petition on behalf of another person. If you are a Violence Against Women Act (VAWA) self-petitioner or special immigrant juvenile, skip to Part 1., Item Number 7. 1. Your Full Name Family Name (Last Name) Given Name (First Name) Middle Name LAZCANO RAMIREZ FERNANDO 2. USCIS Online Account Number (if any) 3. U.S. Social Security Number (if any) 4. Alien Registration Number (A-Number) (if ady) 5. Individual IRS Tax Number (if any) º A- º 6. Mailing Address In Care Of Name (if any) KOFI O AMANKWAA ESQ Organization Name (if applicable) LAW OFFICE Street Number and Name Apt. Ste. Fir. Number 881 GERARD AVE 700 City or Town State ZIP Code BRONX NY 10452 Province Postal Code Country USA Form I-360 Edition 07/15/22 Page 1 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Part J. information About Person or Organization Filing This Petition (continued) 7. Alternate and/or Safe Mailing Address If you are a VAWA self-petitioning spouse, child, parent, or a special immigrant juvenile and do not want U.S. Citizenship and Immigration Services (USCIS) to send notices about this petition to your home, you may provide an alternate and/or safe mailing address. In Care Of Name (if any) SAME Street Number and Name Apt. Ste. Fir. Number O¡¡ City or Town State ZIP Code Province Postal Code Country Part 2. Classification Requested Select only one box. 1. A. ¡ Amerasian B. ¡ Widow(er) of a U.S. citizen C. ¡ Special Immigrant Juvenile D. ¡ Special Immigrant Religious Worker (1) Will the beneficiary be working as a minister? O Yes ¡ No E. ¡ Special Immigrant based on employment with the Panama Canal Company, Canal Zone Government, or U.S. Government in the Canal Zone F. ¡ Special Immigrant Physician G. ¡ Special Immigrant G-4 International Organization Employee or Family Member or NATO-6 Employee or Family Member H. ¡ Special Immigrant Armed Forces Member L ¡ Self-Petitioning Spouse of Abusive U.S. citizen or Lawful Permanent Resident J. ¡ Self-Petitioning Child of Abusive U.S. citizen or Lawful Permanent Resident K. ¡ VAWA Self-Petitioning Parent of a U.S. citizen son or daughter L. ¡ Special Immigrant Afghanistan or Iraq National who worked with the U.S. Armed Forces as a translator M. ¡ Special Immigrant Iraq National who was employed by or on behalf of the U.S. Government N. ¡ Special Immigrant Afghanistan National who was employed by or on behalf of the U.S. Government or the International Security Assistance Force (ISAF) in Afghanistan O. ¡ Broadcasters P. ¡ Other Provide the name of the classification below. Form I-360 Edition 07/15/22 d Page 2 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 "beneficiary" "self-petitioner" NOTE: On this petition, the or means the person for whom this petition is being filed. If you provided an alternate and/or safe mailing address above, you must also complete Part 3. 1. Your Full Name Family Name (Last Name) Given Name (First Name) Middle Name LAZCANO RAMIREZ FERNANDO 2. Mailing Address In Care Of Name (if any) KOFI O AMANKWAA ESQ Street Number and Name Apt. Ste. Fir. Number 881 GERARD AVE 700 City or Town State ZIP Code BRONX NY 10452 Province Postal Code Country USA 3. Date of Birth (mm/dd/yyyy) 4. Country of Birth MEXICO 5. U.S. Social Security Number (if any) 6. A-Num ber (if any) º º A- 7. MaritalStatus ¡ Single ¡ Married ¡ Divorced ¡ Widowed "none," Complete Item Numbers 8. - 15. if this person is in the United States. If an item number is not applicable or the answer is leave the space blank. Provide information below for the passport or other document used at the time of last arrival to the United States. 8. Date of Last Arrival (mm/dd/yyyy) 9. Form I-94 Number or I-95 Crewman's Landing Permit 09/16/2005 º 10. Passport Number 11. Travel Document Number 12. Country of Issuance for Passport or Travel Document 13. Expiration Date for Passport or Travel Document MEXICO (mm/dd/yyyy) 03/11/2031 14. Current Nonimmigrant Status 15. Date current status expired, or will expim as shown on NO STATUS Form I-94 or I-95 (mm/dd/yyyy) I. If the person listed in Part 3. is outside the U S., is meligible to adjust status in the U.S., or does not wish to adjust status m the U.S., provide the following information about the U.S. Consulate at which the person prefers to apply for an immigrant visa. U.S. Consulate A. City or Town B. Country Form 1-360 Edition 07/15/22 . Page3ofl9 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 2. If a U.S. address was provided in Part 3., type or print the person's foreign address below. If he or she does not maintain a foreign address, list the city or town and country of last foreign residence. If his or her native alphabet does not use Roman letters, type or print his or her name and foreign address in the native alphabet. A. Your Full Name Family Name (Last Name) Given Name (First Name) Middle Name LAZCANO RAMIREZ FERNANDO B. Mailing Address Street Number and Name Apt. Ste. Fir. Number City or Town TULANCINGO Province Postal Code Country HIDALGO NEXICO 3. Gender of the beneficiary: E Male ¡ Female 4. A. Are you filing any other petitions or applications with this one? ® Yes ¡ No "Yes" B. If you answered to Item A. in Item Number 4., how many? 3 "Yes" If you answer to Item Numbers 5. - 6., provide an explanation in the space provided in Part 15. Additional Information. 5. Is the beneficiary in removal proceedings? ¡ Yes ® No 6. Has the beneficiary ever worked in the U.S. without permission? (If you are applying for a special E Yes ¡ No immigrant juvenile status, you are not required to answer this itemnumber.) 7. Is an application for adjustment of status attached to this petition? ® Yes ¡ No NOTE: Depending on the classification you seek, you can either file this petition for another person or for yourself. On this petition, "beneficiary" "self-petitioner" the or means the person for whom this petition is being filed, whether that person is yourself or another person. 1. If you are filing as a self-petitioning spouse, have any of your children filed separate self-petitions? ¡ Yes ¡ No 2. Person 1 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- ¡ Spouse ¡ Child Form I-360 Edition 07/15/22 Page 4 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Part 5. Information About the Spouse and Children of the Benef;ciary (coptinued) 3. Person 2 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- ¡ Child 4. Person 3 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- ¡ Child 5. Person 4 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- O Child 6. Person 5 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) . . º A- ¡ Child 7. Person 6 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- ¡ Child Form I-360 Edition 07/15/22 Page 5 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Part 5. information Âbout the Spouse and Children of the Beneficiary (continued) 8. Person 7 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- ¡ Child 9. Person 8 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- ¡ Child 10. Person 9 Family Name (Last Name) Given Name (First Name) Middle Name Date of Birth (mm/dd/yyyy) Country of Birth Relationship A-Number (if any) º A- ¡ Child Part 6. Complete Only If Filing for an Amerasian Information About the Mother of the Amerasian 1. Mother's Full Name Family Name (Last Name) Given Name (First Name) Middle Name 2. A. Is the mother still alive? ¡ Unknown ¡ Yes ¡ No "Yes" B. If you answered to Item A. in Item Number 2., provide her address below. In Care OfName (if any) Street Number and Name Apt. Ste. Fir. Number ¡¡O City or Town State ZIP Code Province Postal Code Country Form I-360 Edition 07/15/22 Page 6 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Part 6. Complete duly If Filing for an Amerasian (continued) "No" C. If you answered to Item A. in Item Number 2., provide her date of death (mm/dd/yyyy). In formation 4bout the Fatherofthe Amerasian If possible, attach a notarized statement from the father regarding parentage. If there is a question you cannot fully answer in the space provided on this petition, use the space provided in Part 15. Additional Information. 3. Father's Full Name Family Name (Last Name) Given Name (First Name) Middle Name 4. Date of Birth (mm/dd/yyyy) 5. Country of Birth 6. A. Is the father still alive? ¡ Unknown ¡ Yes ¡ No "Yes" B. If you answered to Item A. in Item Number 6., provide his address below. In Care Of Name (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country "No" C. If you answered to Item A. in Item Number 6., provide his date of death (mm/dd/yyyy). D. Daytime Telephone Number (if any) E. Work Telephone Number (if any) At the time the Amerasian was conceived: 7. A. The father was in the military (indicate branch of service below). ¡ Army ¡ Air Force ¡ Navy ¡ Marine Corps ¡ Coast Guard B. Provide the father's service number: C. ¡ The father was not in the military and was not a civilian employed abroad. (Attach a full explanation of the circumstances.) l'art 7. Complete Only If filing as a Widow/Widower 1. Full Name of U.S. Citizen Husband or Wife Who Died Family Name (Last Name) Given Name (First Name) Middle Name 2. Date of Birth (mm/dd/yyyy) 3. Country of Birth 4. Date of Death (mm/dd/yyyy) Form I-360 Edition 07/15/22 I Page 7 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Part 7. Complete Only If Filing as a Widow/Widower (continued) 5. At time of death, your spouse was a (Select only one): A. O U.S. citizen born in the United States B. ¡ U.S. citizen born abroad to U.S. citizen parents C. ¡ U.S. citizen through naturalization Provide A-Number (if any) º A- (1) D. ¡ Other (Explain) 6. How many times have you been married? 7. How many times was your spouse married? 8. A. When did you and your spouse get married (mm/dd/yyyy)? B. Where did you and your spouse get married? 9. A. Did you remarry after the death of your spouse? ¡ Yes ¡ No "Yes" B. If you answered to Item A. in Item Number 9., provide the date that you remarried (mm/dd/yyyy). 10. If you are filing as a widow(er), were you legally separated at the time of the U.S. citizen's death? ¡ Yes ¡ No "Yes" NOTE: If you answered to Item Number 10., provide an explanation in the space provided in Part 15. Additional Information. Part 8. Complete Only If Filing for a Special Immigrant Juvenile Information ÄImut che Juvenile 1. List any other names used: A. Family Name (Last Name) Given Name (First Name) Middle Name B. Family Name (Last Name) Given Name (First Name) Middle Name "No" Answer the following questions regarding the person for whom the petition is being filed. If you answer to Item A. in Item Number 2., provide an explanation in the space provided in Part 15. Additional Information. 2. A. Have you been declared dependent on a juvenile court in the United States OR has ajuvenile court ¡ Yes ¡ No legally committed you to, or placed you under the custody of, an agency, department of a state, or an individual or entity? B. Provide the name of the state agency, department, or court-appointed organization or individual with which you are placed below. C. Are you currently under the jurisdiction of the juvenile court that made your placement or custody ¡ Yes ¡ No determination identified in Item B. in Item Number 2. above? Form I-360 Edition 07/15/22 Page 8 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Part S. Complete Only If Filing for a Special linmigrant Jmenile (coDünued) "Yes" 3. A. If you answered to Item C. in Item Number 2. above, are you currently residing in your court-ordered placement? B. "No" If you answered to Item C. in Item Number 2. above, select your reason below. ¡ You were adopted or placed in a permanent guardianship or another permanent living arrangement (other than reunification with the abusive parents). ¡ You aged-out of the juvenile courts jurisdiction and the order was terminated based on age. "Other," ¡ Other. (If you selected provide an explanation in the space provided in Part 15. Additional Information.) 4. A. A juvenile court has determined that reunification with ¡ one or ¡ both of my parents is not viable due to: ¡ Abuse ¡ Neglect ¡ Abandonment ¡ Similar basis under state law (specify): "one" B. If you selected in Item A. in Item Number 4., provide the name of that parent below. 5. Has it been determined in judicial or administrative proceedings that it would not be in your best interest O Yes ¡ No to be returned to your or your parents country of citizenship or nationality or last habitual residence? 6. A. Are you currently or were you previously in the custody of the U.S. Department of Health and ¡ Yes ¡ No Human Services (HHS)? "Yes" B. If you answered to Item A. in Item Number 6., and you are in HHS custody, did the juvenile ¡ Yes ¡ No court order determine or alter your custody status or placement? Part 9. Complete Only If Filing a Special Immigrant lleligious Worker Petition Prospective Employer Attestation 1. Provide the following information about the prospective employer. A. Number of members of the prospective employer's organization B. Number of employees working at the same location where the beneficiary will be employed C. Number of aliens holding special immigrant or nonimmigrant religious worker status who are currently employed or were employed within the past five years D. Number of Special Immigrant Religious Worker (Form I-360) and Nonimmigrant Religious Worker (Form I-129) petitions submitted by the prospective employer within the past five years E. Number of Special Immigrant Religious Worker (Form I-360) petitions submitted by the beneficiary during the last five years 2. Has the beneficiary or have any of the beneficiary's dependent family members previously been admitted O Yes ¡ No to the United States for a period of stay in the Religious Worker (R) classification during the last five years? "Yes" If you answered to Item 2., provide the beneficiary's Number and any dependent family member's prior periods of stay in the R classification in the United States during the last five years. Be sure to provide only those periods when the beneficiary and/or family members were actually in the United States in the R classification. Provide the beneficiary's information in Item Number 3. below. For dependent family members, use the space provided in Part 15. Additional Information. NOTE: Submit photocopies of Form I-94 Arrival-Departure Record, Form I-797 (Notice of Action), and/or other USCIS documents identifying these periods of stay in the R classification. If you need extra space to complete this section, use the space provided in Part 15. Additional Information. Form I-360 Edition 07/15/22 Page 9 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 3. Beneficiary Family Name (Last Name) Given Name (First Name) Middle Name Period of Stay From (mm/dd/yyyy) To (mm/dd/yyyy) 4. Provide a summary of the type of responsibilities of those employees, other than the beneficiary, who work at the same location where the beneficiary will be employed. If you need extra space to complete this section, use the space provided in Part 15. Additional Information. Position Summary of the Type of Responsibilities for That Position 5. Describe the relationship, if any, between the religious organization in the United States and the organization abroad of which the beneficiary is a member. 6. Provide the following information about the prospective employment. If you need extra space to complete this section, use the space provided in Part 15. Additional Information. A. Title of position offered B. The beneficiary will be working (select one of the following): ¡ As a minister ¡ In a religious vocation ¡ In a religious occupation C. Detailed description of the beneficiary's proposed daily duties D. Description of the beneficiary's qualifications for the position offered E. Description of the proposed salaried and/or non-salaried compensation F. Provide the specific addresses or locations where the beneficiary will be working Company Name Street Number and Name Apt. Ste. Fir. Number o¡¡ City or Town State ZIP Code Province Postal Code Country Form I-360 Edition 07/15/22 Page 10 of 19 FILED: BRONX COUNTY CLERK 01/22/2024 10:00 AM INDEX NO. 801163/2024E NYSCEF DOC. NO. 47 RECEIVED NYSCEF: 01/22/2024 Part 9. Complete Only lfFiling a Special Im migrant Religious €orker Petition (continued 7.- "No" 7.- Answer Item Numbers 13. about the prospective employer. If you answer for Item Numbers 13., provide an explanation in the space provided in Part 15. Additional Information. 7. The prospective employer is a bona fide non-profit religious organization or a bona fide organization that ¡ Yes ¡ No is affiliated with the religious denomination and is tax exempt as described in section 501(c)(3) of the Internal Revenue Code of 1986, subsequent amendment, or equivalent sections of prior enactments of the Internal Revenue Code. If the prospective employer is affiliated with the religious denomination, complete the Religious Denomination Certification included in this petition. "Yes," If you answered select the applicable box and attach the appropriate documentation to the petition. A. ¡ A currently valid determination letter from the Internal Revenue Service (IRS) establishing that the