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pdfOMB No. 1615-0097; Expires 05/31/2011
Department of Homeland Security
U. S. Citizenship and Immigration Services
Form G-646, Sworn Statement of Refugee
Applying for Admission into the United States
Penalties
If you knowingly or willfully misrepresent or omit a material fact or submit a false document with this form, we may deny your
immigration benefit. In addition, you may face severe penalties provided by law, including criminal prosecution.
Privacy Act Notice
We ask for the information on this form, and associated evidence, to determine if you are eligible for the immigration benefit you
seek. Failure to provide requested information and/or evidence may delay a final decision or result in denial of your immigration
benefit. We may provide this information to other government agencies.
Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at
20 minutes per response, including the time for reviewing instructions, and completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
U.S. Citizenship and Immigration Services, Regulatory Products Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008,
Washington, DC 20529-2210, OMB No. 1615-0097. Do not mail Form G-646 to this address.
All applicants for refugee status must establish that they are admissible. Use blue or black ink. Check the appropriate box in
response to each question asked below. If your answer to a question is "Yes," provide an explanation on a separate sheet of paper.
Answering "Yes" will not necessarily exclude you from admission to the United States.
A-Number
Name:
Yes
No
Yes
No 1. Have you EVER been detained, arrested, or otherwise placed under the custody or control of a law enforcement
entity for any reason and for any length of time?
Yes
No 2. Have you EVER been cited, charged, indicted, convicted, fined, imprisoned, or otherwise penalized for
breaking or violating any law or ordinance, excluding traffic violations?
Yes
No 3. Have you EVER knowingly committed, or helped someone else commit, any crime(s), excluding traffic
violations, for which you have not been arrested?
4. Have you EVER:
Yes
No
a. Been the beneficiary of a pardon, amnesty, rehabilitation decree, or other act of clemency or similar action?
Yes
No
b. Benefited from diplomatic immunity to avoid prosecution for a criminal offense in the United States or any
other country?
Yes
No
c. Illicitly trafficked (illegally transported, traded, dealt, or sold) in any illegal narcotic or other controlled
substance, or knowingly assisted, abetted, or conspired in the illicit trafficking of any substance?
Form G-646 (Rev. 05/28/10) N
Yes
No
Yes
No
d. Engaged in any unlawful commercialized vice, including but not limited to illegal gambling?
Yes
No
e. Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States
illegally?
Yes
No
f. Within the past 10 years been a prostitute or procured anyone for prostitution?
Yes
No 5. Have you EVER been subject to deportation or removal from the United States?
Yes
No 6. Have you EVER voted illegally in the United States?
Yes
No 7. Have you EVER been a citizen of the United States who has renounced that citizenship to avoid taxation?
Yes
No 8. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces?
Yes
No 9. Have you EVER been subject to a civil document fraud final order for violating section 274C of the
Immigration and Nationality Act of the United States?
Yes
No 10. Are you now withholding custody of a U.S. citizen child outside the United States from a person granted
custody of the child?
Yes
No 11. Did you, during the period March 23, 1933, to May 8, 1945, in association with either Nazi Government of
Germany or any other 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?
Yes
No 12. Have you EVER been a member of, or in any way affiliated with, the Communist party or any totalitarian
party, or any subdivision or affiliate of such parties?
13. Have you EVER:
Yes
No
a. Engaged in, conspired to engage in, or do you intend to engage in sabotage, kidnapping, political
assassination, hijacking, or any other form of terrorist activity?
Yes
No
b. Solicited membership or funds for, or ever voluntarily assisted or provided any type of material support to,
any person or organization that has ever engaged in sabotage, kidnapping, political assassination, hijacking,
or any other form of terrorist activity?
Yes
No
c. Been a representative or member of a terrorist organization?
Yes
No
d. Endorsed or espoused terrorist activity, or persuaded others to endorse or espouse terrorist activity or support
a terrorist organization?
Yes
No
e. Been a member of a political, social, or other group that endorsed or espoused terrorist activity?
Yes
No 14. If married, has your spouse EVER participated in any of the activities listed in Question 13?
Form G-646 (Rev. 05/28/10) N Page 2
Yes
No
Yes
No 15. If between the ages of 14 and 21, has your parent EVER participated in any of the activities listed in Question
13?
16. While in the United States, do you intend to engage in:
Yes
No
a. Espionage?
Yes
No
b. Any activity a purpose of which is opposition to, or the control or overthrow of the Government of the
United States by force, violence, or other unlawful means?
Yes
No
c. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology,
or sensitive information?
Yes
No
d. Polygamy (simultaneous marriage to more than one spouse)?
Yes
No
e. Prostitution?
17. Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any
of the following:
Yes
No
a. Acts involving torture or genocide?
Yes
No
b. Killing any person?
Yes
No
c. Intentionally and severely injuring any person?
Yes
No
d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?
Yes
No
e. Limiting or denying any person's ability to exercise religious beliefs?
18. Have you EVER:
Yes
No
a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit,
self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization?
Yes
No
b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved
detaining persons?
Yes
No 19. Have you EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind
in which you or other persons used any type of weapon against any person or threatened to do so?
Yes
No 20. Have you EVER assisted or participated in selling or providing weapons to any person who to your
knowledge used them against another person, or in transporting weapons to any person who to your knowledge
used them against another person?
Yes
No 21. Have you EVER received any type of military, paramilitary, or weapons training?
Yes
No 22. Have you EVER knowingly recruited a child under 15 years of age to serve in an armed force or group or
used a child under 15 years of age to participate actively in hostilities?
Form G-646 (Rev. 05/28/10) N Page 3
Yes
No
Yes
No 23. Have you, by fraud or willful misrepresentation of a material fact, EVER sought to procure, or procured, a
visa, other documentation, entry into the United States, or any other immigration benefit?
24. Do you:
Yes
No
a. Currently have any communicable disease of public health significance (including chancroid, gonorrhea,
granuloma inguinal, human immunodeficiency virus (HIV) infection, infectious leprosy, lymphogranuloma
venereum, infectious stage syphilis, and active tuberculosis)?
Yes
No
b. Have a physical or mental disorder, and behavior associated with the disorder, that may pose, or has posed, a
threat to the property, safety, or welfare of yourself or others?
Yes
No 25. Are you a narcotics user or addict?
Applicant's Statement and Signature (Check one)
I can read and understand English, and I have read and understand each and every question and instruction on this form, as well
as my answer to each question.
Each and every question and instruction on this form, as well as my answer to each question, has been read to me in the
language, a language in which I am fluent, by the person named in Interpreter's Statement and
Signature. I understand each and every question and instruction on this form, as well as my answer to each question.
I certify, under penalty of perjury under the laws of the United States of America, that the information provided with this Form G-646
is all true and correct. I certify also that I have not withheld any information that would affect the outcome of this Form G-646.
Applicant's Signature
E-Mail Address (if any)
Date (mm/dd/yyyy)
Interpreter's Statement and Signature
I certify that I am fluent in English and the below-mentioned language.
Language Used (language in which applicant is fluent):
I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this
applicant in the above-mentioned language, and the applicant has understood each and every instruction and question on the form, as
well as the answer to each question.
Interpreter's Signature
Printed Name
Date (mm/dd/yyyy)
E-Mail Address (if any)
Telephone Number (with area/country code)
Form G-646 (Rev. 05/28/10) N Page 4
Preparer's Statement and Signature
I declare that I prepared this Form G-646 at the request of the above applicant and it is based on all information of which I have
knowledge. I have not knowingly withheld any material information that would affect the outcome of this Form G-646.
Attorney or Representative: In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
Yes
No
Preparer's Signature
Date (mm/dd/yyyy)
Preparer's Printed Name
Preparer's Firm Name (if applicable)
Preparer's Address
Daytime Phone Number (with area code)
Fax Number (if any)
E-Mail Address (if any)
OFFICIAL USE ONLY
Subscribed and sworn to (affirmed) by the named applicant before me.
Date (mm/dd/yyyy)
Location:
Official:
Signature
Official:
Printed Name
Form G-646 (Rev. 05/28/10) N Page 5
| File Type | application/pdf |
| File Modified | 2010-06-22 |
| File Created | 2010-03-11 |