Form I-694 Notice of Appeal of Decision Under Section 210 or 245A

OMB No. 1615-0034; Expires 09/30/2011

I-694, Notice of Appeal of
Decision Under Section 210 or 245A

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

For USCIS use Only
Fee Stamp

Action Block

APPELLANT - START HERE: Please type or print in black ink.
In the Matter of:

File Number: AApplication for one of the following:

Permanent Residence (I-698)
Temporary Residence (I-687)
Waiver of Grounds of Inadmissibility
I hereby appeal to the USCIS Director from the decision, dated

in the above entitled case.

My written brief or statement is attached.
I waive the right to submit a written brief or statement.
I will submit a brief within 30 calendar days.

Summarize the reasons for this appeal.
The appeal must include a statement explaining any error or conclusion of law in the
decision being appealed or any erroneous statement of fact stated in the decision.

Appellant (or Attorney or Representative): Please complete the following.
Name (Last Name, First Name, Full Middle Name)
Address ( Street Name and Number)
(City or Town)

Telephone Number With Area Code
(State)

(Zip Code)

Title or Relationship to Appellant, If Other Than Appellant
Signature

Date (mm/dd/yyyy)

Form I-694 (Rev.11/23/10) Y