Form I-601 Application for Waiver of Grounds of Inadmissibility

USCIS
Form I-601

Application for Waiver of Grounds of Inadmissibility
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0029
Expires 06/30/2012

DRAFT - Not
Initial
Receipt

Fee Stamp

For
USCIS
Use
Only

Action Block

Resubmitted

Relocated
Received
Sent

Benefits Category
Immigrant
Adjustment of Status
TPS
V Nonimmigrant
K Nonimmigrant

Inadmissible Under
212(a)(1)
212(a)(2)

212(a)(3)
212(a)(4)

For

To Be Completed by an
Attorney or Representative, if any.

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

212(a)(10)
Other

Fill in box if G-28 is attached to represent the applicant.
Attorney State License Number:

► START HERE - Type or print in black ink.

Production

Part 1. Information About Applicant
1.

Alien Registration Number (A-Number)
► A-

2.

Contact Information

5.

(

Applicant's U.S. Social Security Number (optional)
►

Daytime Phone Number (if any)

6.

)

Extension

-

E-mail Address (if any)

Your Full Name
Other Information

3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

7.

Date of Birth (mm/dd/yyyy) ►

8.

City or Town of Birth

9.

Province of Birth (if applicable)

10.

Country of Birth

11.

Country of Citizenship

3.c. Middle Name

Address
4.a. Street Number
and Name
4.b. Apt.

Ste.

Flr.

4.c. City or Town
4.d. State

4.e. Zip Code

4.g. Province

If you are outside the United States and you were already
interviewed by a Department of State (DOS) consular officer at
a U.S. Embassy or consulate, provide information in item
number 12.a. - 12.c.

4.h. Country

12.a. Date of Visa Application with DOS

4.f.

Postal Code

(mm/dd/yyyy) ►
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Page 1 of 9

Part 1. Information About Applicant (continued)

DRAFT - Not

12.b. Location of Visa Application with DOS

17.

I have been involved in a crime of moral turpitude
(other than a purely political offense) (see
instructions).

12.c. Department of State Consular Case Number

18.

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

I have been convicted of 2 or more offenses, other
than purely political ones, for which the combined
sentences to confinement were 5 years or more (see
instructions).

19.

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 (see
instructions).

Yes
13.b. If "Yes", provide USCIS Receipt #
►
13.c. Filing Location

No

For
20.

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 (see instructions).

21.

I am coming to the United States to engage in any
other unlawful commercialized vice, whether or not
related to prostitution (see instructions).

22.

I have been involved in serious criminal activity and
have asserted immunity from prosecution (see
instructions).

23.

I have sought to procure an immigration benefit by
fraud or by concealing or misrepresenting a material
fact (immigration fraud or misrepresentation) (see
instructions).

24.

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 (see instructions).

25.

I have been engaged in alien smuggling (see
instructions).

26.

I am subject to a civil penalty because I have been the
subject of a final order for violation of the
Immigration and Nationality Act (INA) section 274C
(see instructions).

27.

I am subject to the 3-year or the 10-year bar to
admissibility because I was previously unlawfully
present in the United States in excess of either 180
days or 1 year or more, and subsequently departed
the United States (see instructions).

28.

I was previously removed from the United States (see
instructions for NACARA and HRIFA applicants
only. All other applicants, file Form I-212).

13.d. Date Filed (mm/dd/yyyy) ►

Reason(s) for Inadmissibility

Production

Mark all of the following grounds that you believe, according to
the best of your knowledge, apply to you. Only mark the
applicable ground(s) listed under the immigration benefit you
are seeking.
In the space provided for item number 51, include a statement
explaining the acts, convictions, and medical conditions that
you believe make you inadmissible.

If you seek a waiver of inadmissibility because you have a Class
A Tuberculosis condition (as per HHS regulations), you must
complete the last 2 pages 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 believe that I
am inadmissible because: (See the form instructions
for a detailed explanation of the individual grounds.)

Check all that apply
14.

15.

16.

I have a communicable disease of public health
significance, as per HHS regulations (see
instructions).
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 (see
instructions).
I seek an exemption from the vaccination
requirement because it is against my religious beliefs
or moral convictions (see instructions).

Form I-601 02/22/12 N

Page 2 of 9

Part 1. Information About Applicant (continued)

DRAFT - Not

Reason(s) for Inadmissibility (continued)
29.

30.

B.

31.

C.

I have been ordered removed, or I have been
unlawfully present in the United States for more than
1 year, in the aggregate, and I subsequently reentered
or attempted to reenter without being admitted (see
instructions for NACARA, HRIFA, and the
instructions for approved VAWA self-petitioners
only. Other applicants, file Form I-212).
Other (specify)

33.

34.

I am applying for TPS and I believe that I am
inadmissible because: (see instructions)

I have a communicable disease of public health
significance. (A list of communicable diseases of
public health significance can be found in the
instructions).
I have or I 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.
Within the past 10 years, I have engaged in
prostitution (including receiving the proceeds of, in
full or in part) or procurement of prostitution, or
continue to engage in prostitution or procurement of
prostitution.

35.

I am or I have been a drug abuser or drug addict as
described in Department of Health and Human
Services Regulations. See 42 CFR Part 34.

36.

I have been or I intend to be involved in any other
commercialized vice.

Form I-601 02/22/12 N

38.

I am subject to a final order for violation of INA
section 274C (producing/using false documentation
to unlawfully satisfy a requirement of the INA).

39.

I did not attend or did not remain at a removal
proceeding to determine my inadmissibility or
deportability.

40.

I practice polygamy.

41.

I am accompanying another alien who is inadmissible
after being certified to be helpless under INA section
232(c), and I am inadmissible because that other alien
requires my protection or guardianship.

42.

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.

Production

Check all that apply
32.

I have committed a serious criminal offense in the
United States and asserted immunity from
prosecution.

For

I am applying for adjustment of status based on a
valid T nonimmigrant status and I believe that I am
inadmissible because: (see instructions)
Specify:

37.

43.

I was an unlawful voter who voted in violation of a
Federal, State, or local constitutional provision,
statute, ordinance, or regulation.

44.

I am a former United States citizen who renounced
my citizenship in order to avoid taxation by the
United States.

45.

I tried to obtain a visa, other documentation, or
admission into the United States or other benefit by
fraud or willfully misrepresenting a material fact.

46.

I falsely represented myself as a U.S. citizen.

47.

I have assisted another person to enter the United
States in violation of the law.

48.

I am ineligible for U.S. citizenship because I obtained
a discharge from the U.S. Armed Forces for the
reason that I am an alien OR because I received an
exemption from the military draft for the reason that I
am an alien.

49.

I have been involved in a single offense of simple
possession of 30 grams or less of marijuana.

50.

Other (specify)

Page 3 of 9

Part 1. Information About Applicant (continued)

DRAFT - Not

Reason(s) for Inadmissibility (continued)

51.

Statement From Applicant

In the space provided in number 51, describe in your own
words why you believe that you are inadmissible and all the
reasons that you believe support your request for a waiver.

Your statement must explain the acts, convictions, and/or
medical conditions that make you inadmissible. Your statement
must indicate when you engaged in the acts that you believe
make you inadmissible, the date of all convictions, or the date
of any medical diagnosis. You must provide this information in
number 51, even if the information is also in the documents
that you submit with your application according to the form
instructions.

For

Your statement must also explain why you believe your
application should be approved as a matter of discretion, with
the favorable factors outweighing the unfavorable factors in
your case. If your application requires the showing of extreme
hardship to a qualifying relative, you must explain the hardship
that your qualifying relative has or will experience if you are
refused the immigration benefit you are seeking.

Production

If you intend to submit a statement in a separate letter, you may
do so but you must write into the space in number 51, that you
are attaching a letter that explains the acts, convictions, or
medical conditions that you believe make you inadmissible. The
letter must be submitted at the same time as your Form I-601
application.
NOTE: You should include copies of any documents that
support your statement, with your Form I-601 application
packet. Records of convictions must be certified from the
court in which you were convicted; copies will not be
sufficient.
NOTE: If you require more space to complete your statement,
use the space provided in Part 6.

Form I-601 02/22/12 N

Page 4 of 9

Part 1. Information About Applicant (continued)

DRAFT - Not

Applicant was previously in the United States as follows:
52.a. City or Town

54.a. City or Town

52.b. State

54.b. State

52.c. Date From (mm/dd/yyyy) ►
52.d. Date To

(mm/dd/yyyy) ►

52.e. Immigration Status

54.c. Date From (mm/dd/yyyy) ►
54.d. Date To

(mm/dd/yyyy) ►

54.e. Immigration Status

For

53.a. City or Town

55.a. City or Town

53.b. State

55.b. State

53.c. Date From (mm/dd/yyyy) ►

55.c. Date From (mm/dd/yyyy) ►

(mm/dd/yyyy) ►

53.d. Date To

55.d. Date To

(mm/dd/yyyy) ►

Production

53.e Immigration Status

55.e. Immigration Status

Part 2. Information About Relative Through Whom Applicant Claims Eligibility, Where Applicable
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Other Information
3.

Daytime Phone Number

(

1.c. Middle Name

)

Extension

-

4.

E-mail Address (if any)

5.

Relationship to Applicant

6.

Immigration Status

Physical Address
2.a. Street Number
and Name
2.b. Apt.

Ste.

Flr.

2.c. City or Town
2.d. State
2.f.

Postal Code

2.e. Zip Code

Check here if the applicant has additional relatives
through whom the applicant claims eligibility. Please go
to Part 6 and provide the same information as requested
in Part 2, numbers 1.a. through 6.

2.g. Province
2.h. Country

Form I-601 02/22/12 N

Page 5 of 9

Part 3. Information About Applicant's Other Relatives in the United States
(List only U.S. citizens and permanent residents)

DRAFT - Not

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Other Information

3.

Daytime Telephone Number

(

1.c. Middle Name

)

Extension

-

4.

E-mail Address (if any)

5.

Relationship to Applicant

Physical Address
2.a. Street Number
and Name
2.b. Apt.

Ste.

Flr.

2.c. City or Town
2.d. State

For
6.

Immigration Status

Check here if the applicant has additional relatives in the
United States. Please go to Part 6 and provide the same
information as requested in Part 3, numbers 1.a.
through 6.

2.e. Zip Code

Part 4. Signature of Applicant

Production

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.

1.a. Signature of Applicant (See the instructions)

1.b. Date of Signature (mm/dd/yyyy) ►

I furthermore authorize release of information contained in this
form, supporting documents, and my USCIS records to other
entities and persons where necessary for the administration of
U.S. immigration laws.

Part 5. Signature of Person Preparing This Application, If Other Than the Applicant
NOTE: If you are an attorney or representative, you must
submit a completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, along with this
application.

Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)

Preparer's Mailing Address
3.a. Street Number
and Name
3.b. Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. Zip Code

Postal Code

1.b. Preparer's Given Name (First Name)
3.g. Province
2.

Preparer's Business or Organization Name

Form I-601 02/22/12 N

3.h. Country

Page 6 of 9

Part 5. Signature of Person Preparing This Application, If Other Than the Applicant (continued)

DRAFT - Not
Declaration

Preparer's Contact Information
4.

Preparer's Daytime Phone Number

(
5.

)

-

Preparer's E-mail Address (if any)

Extension

I declare that this document was prepared by me at the request of
the applicant or other individual authorized by the form
instructions to sign this application (see the instructions), 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.
6.a. Signature
of Preparer

For

6.b. Date of Signature (mm/dd/yyyy) ►

Part 6. Additional Information

If you require more space to complete an item, please use the space below. In order to assist us in reviewing your response, you must
identify the Part Number and Item Number.
1.

2.

Production

Form I-601 02/22/12 N

Page 7 of 9

To Be Completed for Applicants With Class A Tuberculosis Condition (As Per HHS Regulations)

DRAFT - Not

Section A. Statement by Applicant

2.a. Name of Health Department (Type or print in black ink)

Upon admission to the United States I will:

2.b. Street Number
and Name

A.

Go directly to the health department named in Section B;

B.

Present all X-rays used in the visa medical examination to
substantiate diagnosis;

2.c. Apt.

C.

Submit to such examinations, treatment, isolation, and
medical regimen as may be required; and

2.d. City or Town

D.

Remain under the prescribed treatment or observation,
whether on inpatient or outpatient basis, until discharged.

2.e. State

1.a. Signature of Applicant

1.b. Date of Signature (mm/dd/yyyy) ►

Ste.

Flr.

2.f.

For

Zip Code

3.a. Signature of Physician

3.b. Date of Signature (mm/dd/yyyy) ►
3.c. Printed Name of Physician

Section B. Statement by Local (City or County)
Health Department
NOTE: The physician at the local health department in the area
where the alien plans to reside should complete this statement.

3.d. Daytime Phone Number

(

)

Extension

Production

I agree to supply any treatment or observation necessary for the
proper management and continued care of the alien's
tuberculosis condition.

I agree to submit a summary of my initial evaluation of the
alien's condition to the State Health Department Official named
in Section D and to the Division of Global Migration and
Quarantine (E03), Centers for Disease Control and
Prevention (CDC), Atlanta, Georgia 30333:
A. Within 30 days of the alien reporting for care, indicating
presumptive diagnosis, test results, and plans for future
care of the alien; or
B. A report that the alien has not reported within 30 days after
receiving notice from the Division of Global Migration and
Quarantine, CDC.

3.e. E-mail Address (if any)

Section C. Arrangement for Medical Care by the
Applicant or His or Her Sponsor
Arrange for medical care (of the applicant) and have the
appropriate Health Departments complete Sections B and D.
Provide the following information:
Address where you or the applicant plan to reside in the United
States:
1.a. Street Number
and Name
1.b. Apt.

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.)

-

Ste.

Flr.

1.c. City or Town
1.d. State

1.e. Zip Code

I represent (enter an "X" in the appropriate box and give the
complete name, address, and phone number of the health
department below):
1.a.

City Health Department

1.b.

County Health Department

Form I-601 02/22/12 N

Page 8 of 9

To Be Completed for Applicants With Class A Tuberculosis Condition (As Per HHS Regulations)

DRAFT - Not

Section D. Endorsement of State Health Department
Official

NOTE: The State Health Department Official in the area where
the applicant plans to reside should complete this statement.

Endorsement signifies recognition of the local health
department that completed Section B for the purpose of
providing care and treatment of the applicant's tuberculosis
condition, and that the local health department is within your
jurisdiction. Endorsement also signifies recognition that the
applicant will be residing within your State's health jurisdiction.
Endorsed by:

2.a. Name of State Health Department (Type or print in black
ink)

2.b. Street Number
and Name

2.c. Apt.

Ste.

Flr.

2.d. City or Town

For
2.e. State

2.f.

Zip Code

2.g. Daytime Phone Number

1.a. Signature of State Health Department Official

(

)

Extension

-

2.h. E-mail Address (if any)
1.b. Date of Signature (mm/dd/yyyy) ►
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).

Production

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 02/22/12 N

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