Form I-601 Form I-601 Application for Waiver of Ground of Excludability

Application for Waiver of Ground of Inadmissibility

I-601 Form_FR2010

Application for Waiver of Ground of Excludability

OMB: 1615-0029

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OMB No. 1615-0029; Expires 04/30/11

I-601, Application for Waiver
of Grounds of Inadmissibility

Department of Homeland Security
U.S. Citizenship and Immigration Services

Do not write in this block. For Government use only.
Inadmissible under:

Benefits Category:
Immigrant
Adjustment of Status
V nonimmigrant
K nonimmigrant
TPS

Fee Stamp

212(a)(1)
212(a)(2)
212(a)(3)

212(a)(6)
212(a)(9)

212(a)(4)

Other

212(a)(10)

Action Stamp

Initial Receipt

Resubmitted

Relocated
Received

Sent

A. Information About Applicant
1. Family Name (Surname In CAPS)

3. (Town or City)

(First)

(State/Country)

6. Date of Birth (mm/dd/yyyy)

(Middle)

(Zip/Postal Code)

7. USCIS File Number

2. Address (Number and Street)

4. Telephone Number

(Apartment Number)

5. E-Mail Address

8. City/Province-State of Birth

A9a. Country of Birth

9b. Country of Citizenship/Nationality

10. Date of Visa Application

11. Location of Visa Application:

10. Reason(s) for Inadmissibility: (Mark all of the grounds listed below that you believe, according to the best of your knowledge,
apply to you. Then, in the space provided on Page 3, include a statement explaining the acts, convictions, and medical conditions
that make you inadmissible. Your statement must indicate when you engaged in the acts that make you inadmissible, the date of
all convictions, and the date of any medical diagnosis. If you seek a waiver of inadmissibility because you have a Class A
Tuberculosis condition (as per HHS regulations), you must complete Page 6 of this form. If you seek a waiver of inadmissibility
because of a history of physical or mental disorders, you must attach the information requested in the instructions.)
a) I am an applicant for an immigrant visa or adjustment of status (other than based on T nonimmigrant status), or for K
or V nonimmigrant status, and I am inadmissible because: (See the form instructions for a detailed explanation of the
individual grounds.)
CHECK ALL THAT APPLY
I have a communicable disease of public health significance, as per HHS regulations (Page 3 of the instructions).
I seek an exemption from the vaccination requirement because it is against my religious beliefs or moral convictions (Page 4 of the
instructions).
Form I-601 (Rev. 08/20/10)Y

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I have, or have had in the past, a physical or mental disorder and behavior associated with the disorder that poses, may pose, or has posed, a
threat to the property, safety, or welfare of myself or others (pages 3 and 4 of the instructions).
I have been involved in a crime of moral turpitude (other than a purely political offense) (Page 4 of the instructions).
I have been involved in a controlled substance violation according to the laws and regulations of any country that involved a single offense of
simple possession of 30 grams or less of marijuana (Page 4 of the instructions).
I have been convicted of two or more offenses, other than purely political ones, for which the combined sentences to confinement were five
years or more (Page 4 of the instructions).
I have, within the last 10 years, been involved in prostitution, or I am currently involved in prostitution. "Involved in" prostitution means being
a prostitute, procuring or attempting to procure others for prostitution, importing other individuals to engage in prostitution, or receiving the
proceeds, in full or in part, from prostitution (Page 4 of the instructions).
I am coming to the United States to engage in any other unlawful commercialized vice, whether or not related to prostitution (Page 4 of the
instructions).
I have been involved in serious criminal activity and have asserted immunity from prosecution (Page 4 of the instructions).
I am or I have been a member of or affiliated with the Communist or any other totalitarian party (or subdivision or affiliate of the party),
domestic or foreign (Page 5 of the instructions).
I have sought to procure an immigration benefit by fraud or by concealing or misrepresenting a material fact (immigration fraud or
misrepresentation)(pages 4 and 5 of the instructions).
I have been engaged in alien smuggling (Page 5 of the instructions).
I am subject to a civil penalty because I have been the subject of a final order for violation of INA section 274C (Page 5 of the instructions).
I am subject to the three-year or the 10-year bar to admissibility because I have been unlawfully present in the United States in excess of either
180 days or one year, and subsequently departed the United States (Page 5 of the instructions).
I was previously removed from the United States (Page 6 of the instructions for NACARA and HRIFA applicants only. All other applicants,
file Form I-212).
I have been ordered removed, or I have been unlawfully present in the United States for more than one year, in the aggregate, and I
subsequently reentered or attempted to reenter without being admitted (Page 6 of the instructions for NACARA, HRIFA, and approved
VAWA self-petitioners only. Other applicants, file Form I-212).
Other (specify):

b) I am applying for adjustment of status based on a valid T nonimmigrant status, and I am inadmissible because (See Page 7
of the instructions):
Specify:

c) I am an applicant for TPS, and I am inadmissible because (Page 6 of the instructions):
CHECK ALL THAT APPLY
I have a communicable disease of public health significance (a list of communicable diseases of public health significance can be found on
Page 3 of the instructions).
I have or I have had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated with the disorder,
which has posed or may pose a threat to the property, safety, or welfare of myself or others.
I have, within the past 10 years, engaged in prostitution (including receiving the proceeds of, in full or in part), procurement of prostitution, or
continue to engage in prostitution or procurement of prostitution.
I am or have been a drug abuser or drug addict.
Form I-601 (Rev. 08/20/10)Y Page 2

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I have been or I intend to be involved in any other commercialized vice.
I have committed a serious criminal offense in the United States and asserted immunity from prosecution.
I entered the United States as a stowaway.
I am subject to a final order for violation of section 274C (producing/using false documentation to unlawfully satisfy a requirement of the
Immigration and Nationality Act).
I practice polygamy.
I have attempted, conspired, or engaged in the recruitment or use of child soldiers in violation of Title 18, United States Code, section 2442 by
recruiting, enlisting, or conscribing a person under the age of 15 years in an armed force, or by using such a person to participate actively in
hostilities.
I am accompanying another alien who is inadmissible after being certified to be helpless under section 232(c) of the Act and I am inadmissible
because that other alien requires my protection or guardianship.
I have detained, retained, or withheld the custody of a child having a lawful claim to U.S. citizenship, outside the United States, from
a U.S. citizen granted custody.
I have been excluded and deported from the United States within the past year, or have been deported or removed from the United States at
government expense within the last five years (20 years if you have been convicted of an aggravated felony).
I have assisted another person to enter the United States in violation of the law.
Other (specify):
For ALL applicants: Describe in your own words why you are inadmissible:

Form I-601 (Rev. 08/20/10)Y Page 3

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A. Information About Applicant (Continued)
12. Applicant's U.S. Social Security Number (if any)

11. Applicant was previously in the United States as follows:
City and State

From (Date)

To (Date)

Immigration Status
13. If in the United States: Did you file this application after you
have already filed Form I-485 or Form I-821?

Yes

If "Yes," provide the following information:
Receipt No.:
Filing location:
Date filed:

B. Information About Relative Through Whom Applicant Claims Eligibility
First Name

1. Family Name (Surname in CAPS)

2. Address (Number and Street)

3. Telephone Number

Apt. Number

4. E-Mail Address

Town or City

Middle Name

Zip/Postal Code

State

5. Relationship to Applicant

6. Immigration Status

Check here if the applicant has additional relatives through whom the applicant claims eligibility. Provide the same information
as requested in B. 1-5 on a separate sheet of paper.
C. Information About Applicant's Other Relatives in the United States (List only U.S. citizens and permanent residents)

2. Address (Number and Street)

3. Telephone Number

Middle Name

First Name

1. Family Name (Surname in CAPS)

Apt. Number

4. E-Mail Address

Town or City

State

5. Relationship to Applicant

Zip/Postal Code

6. Immigration Status

Form I-601 (Rev. 08/20/10)Y Page 4

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C. Information About Applicant's Other Relatives in the United States (Continued)
1. Family Name (Surname in CAPS)

2. Address (Number and Street)

3. Telephone Number

1. Family Name (Surname in CAPS)

3. Telephone Number

Town or City

Apt. Number

4. E-Mail Address

2. Address (Number and Street)

Middle Name

First Name

State

5. Relationship to Applicant

First Name

Apt. Number

Town or City

4. E-Mail Address

Zip/Postal Code

6. Immigration Status

Middle Name

State

5. Relationship to Applicant

Zip/Postal Code

6. Immigration Status

D. Applicant's Signature and Certification
I certify under penalty of perjury under the laws of the United States that this application and the evidence submitted with it are all
true and correct to the best of my knowledge and abilities. I authorize the release of any information from my records that U.S.
Citizenship and Immigration Services (USCIS) needs to determine my eligibility for this waiver.

Date

Signature of Applicant or Qualified Relative / Legal Guardian
E. Preparer's Signature and Certification

I declare that this document was prepared by me at the request of the applicant or qualified relative/legal guardian of the applicant,
and it is based on all information of which I have knowledge and/or was provided to me by the above named person in response to the
exact questions contained on this form. I have not knowingly withheld any information.
Preparer's Signature

Preparer's Family Name (Surname in CAPS)

Preparer's Street Address

Date

Telephone Number

First Name

Town or City

E-Mail Addresss

Middle Name

State

Zip/Postal Code

Form I-601 (Rev. 08/20/10)Y Page 5

To Be Completed forDRAFT
Applicants With Class A
Tuberculosis Condition (As Per HHS Regulations)
A. Statement by Applicant
Upon admission to the United States I will:
1. Go directly to the physician or health facility named in
Section B;
2. Present all X-rays used in the visa medical examination to
substantiate diagnosis;
3. Submit to such examinations, treatment, isolation, and
medical regimen as may be required; and
4. Remain under the prescribed treatment or observation,
whether on inpatient or outpatient basis, until discharged.
Signature of Applicant

If medical care will be provided by a physician who checked
Box 2 or 3, in Section B, have Section D completed by the local
or State health officer who has jurisdiction in the United States
area where the applicant plans to reside.
If medical care will be provided by a physician who checked
Box 4 in Section B, forward this form directly to the military
facility at the address provided in Section B.
Provide the following information:
Address where you or the applicant plan to reside in the United
States:

Date

Address (Number and Street)

B. Statement by Physician or Health Facility
(A private physician, health department, other public or private
health facility, or military hospital may execute this statement.
Attach a supporting statement on the facility's letterhead
evidencing that arrangements for treatment have been made by
the applicant or his or her sponsor.)
I agree to supply any treatment or observation necessary for the
proper management of the alien's tuberculosis condition.
I agree to submit Form CDC 75.18, "Report on Alien with
Tuberculosis Waiver," to the health officer named in Section D:
1. Within 30 days of the alien's reporting for care, indicating
presumptive diagnosis, test results, and plans for future
care of the alien; or
2. Thirty days after receiving Form CDC 75.18, if the alien
has not reported.
Satisfactory financial arrangements have been made. (This
statement does not relieve the alien from submitting evidence,
as required by a U.S. consulate, to establish that the alien is
not likely to become a public charge.)
I represent (enter an "X" in the appropriate box and give the
complete name and address of the facility below):
1.
2.
3.
4.

Local Health Department
Other Public or Private Facility
Private Practice
Military Hospital

Address (Number and Street)
City, State, and Zip Code

Date

E-Mail Address

D. Endorsement of Local or State Health Officer
Endorsement signifies recognition of the physician or facility for
the purpose of providing care for tuberculosis. If the facility or
physician who signed his or her name in Section B is not in your
health jurisdiction and not familiar to you, you may want to
contact the health officer responsible for the jurisdiction of the
facility or physician prior to endorsing.
Endorsed by: Signature of Health Officer

Date:
Enter below the name and address of the local health department
where the "Notice of Arrival of Alien with Tuberculosis
Waiver" will be sent when the alien arrives in the United States.
Official Name of Department
(Room/Suite Number)

City, State, and Zip Code

(Room/Suite Number)

Signature of Physician

Apt Number

City, State, and Zip Code

Address (Number and Street)

Name of Facility (Type or print in black ink)

Phone Number

C. Arrangement for Medical Care by the Applicant or His
or Her Sponsor
Arrange for medical care (of the applicant) and have the
physician or facility that will provide the medical care complete
Section B.

Phone Number

E-Mail Address

Note to the Applicant and his or her Sponsor: If you need assistance, contact
USCIS at the National Customer Service Center at 1-800-375-5283. You may
also schedule an appointment at the local USCIS office through InfoPass
(available through USCIS' Web site at www.uscis.gov).
Note to the Applicant: If you are approved for a waiver and after admission to
the United States you fail to comply with the terms, conditions, and controls that
were imposed with the grant of the waiver, you may be subject to removal under
Immigration and Nationality Act (INA) section 237(a).
Form I-601 (Rev. 08/20/10)Y Page 6

DRAFT

OMB No. 1615-0029; Expires 04/30/11

I-601, Application for Waiver
of Grounds of Inadmissibility

Department of Homeland Security
U.S. Citizenship and Immigration Services

Do not write in this block. For Government use only.
Inadmissible under:

Benefits Category:
Immigrant
Adjustment of Status
V nonimmigrant
K nonimmigrant
TPS

Fee Stamp

212(a)(1)
212(a)(2)
212(a)(3)

212(a)(6)
212(a)(9)

212(a)(4)

Other

212(a)(10)

Action Stamp

Initial Receipt

Resubmitted

Relocated
Sent

Received

A. Information About Applicant
1. Family Name (Surname In CAPS)

3. (Town or City)

(First)

(State/Country)

6. Date of Birth (mm/dd/yyyy)

(Middle)

(Zip/Postal Code)

7. USCIS File Number

(Apartment Number)

2. Address (Number and Street)

4. Telephone Number

5. E-Mail Address

8. City/Province-State of Birth

A9a. Country of Birth

9b. Country of Citizenship/Nationality

10. Date of Visa Application

11. Location of Visa Application:

Form I-601 (Rev. 08/20/10)Y

DRAFT

b) I am applying for adjustment of status based on a valid T nonimmigrant status, and I am inadmissible because (See Page 7
of the instructions):
Specify:

Agency Copy

Form I-601 (Rev. 08/20/10)Y Page 2

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Agency Copy

Form I-601 (Rev. 08/20/10)Y Page 3

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A. Information About Applicant (Continued)
12. Applicant's U.S. Social Security Number (if any)

11. Applicant was previously in the United States as follows:
City and State

From (Date)

To (Date)

Immigration Status
13. If in the United States: Did you file this application after you
have already filed Form I-485 or Form I-821?

Yes

If "Yes," provide the following information:
Receipt No.:
Filing location:
Date filed:

B. Information About Relative Through Whom Applicant Claims Eligibility
First Name

1. Family Name (Surname in CAPS)

2. Address (Number and Street)

3. Telephone Number

Apt. Number

4. E-Mail Address

Town or City

Middle Name

Zip/Postal Code

State

5. Relationship to Applicant

6. Immigration Status

2. Address (Number and Street)

3. Telephone Number

Middle Name

First Name

1. Family Name (Surname in CAPS)

Apt. Number

4. E-Mail Address

Town or City

State

5. Relationship to Applicant

Agency Copy

Zip/Postal Code

6. Immigration Status

Form I-601 (Rev. 08/20/10)Y Page 4

DRAFT

C. Information About Applicant's Other Relatives in the United States (Continued)
1. Family Name (Surname in CAPS)

2. Address (Number and Street)

3. Telephone Number

1. Family Name (Surname in CAPS)

3. Telephone Number

Town or City

Apt. Number

4. E-Mail Address

2. Address (Number and Street)

Middle Name

First Name

State

5. Relationship to Applicant

First Name

Apt. Number

Town or City

4. E-Mail Address

Zip/Postal Code

6. Immigration Status

Middle Name

State

5. Relationship to Applicant

Zip/Postal Code

6. Immigration Status

Date

Signature of Applicant or Qualified Relative / Legal Guardian
E. Preparer's Signature and Certification

Preparer's Family Name (Surname in CAPS)

Preparer's Street Address

Date

Telephone Number

First Name

Town or City

E-Mail Addresss

Middle Name

State

Agency Copy

Zip/Postal Code

Form I-601 (Rev. 08/20/10)Y Page 5

File Type	application/pdf
File Modified	2010-09-01
File Created	2008-06-10