I-601 Form TOC

TABLE OF CHANGES - FORM

Form I-601, Application for Waiver of Grounds of Inadmissibility

OMB No 1615-0029

Date: 12/22/2014

Current Location	Current Text	Location and Proposed Text
Page 1, Part 1. Information About Applicant To align with USCIS ELIS requirements	Part 1. Information About Applicant 1. Alien Registration Number (A-Number) 2. Applicant's U.S. Social Security Number (optional) 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 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.f. Postal Code 4.g. Province 4.h. Country 5. Daytime Phone Number (if any) Extension 6. E-mail Address (if any) 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 If you are outside of the United States and you were already interviewed by the Department of State (DOS) consular officer at a U.S. Embassy or consulate, provide information in item number 12.a. – 12.c. 12.a. Date of Visa Application with DOS 12.b. Location of Visa Application with DOS 12.c. Department of State Consular Case Number 13.a. If in the United States: Did you file this application after you have already filed Form I-485 or Form I-821? Y/N 13.b. If “Yes”, provide USCIS Receipt # 13.c. Filing Location 13.d. Date Filed (mm/dd/yyyy)	Part 1. Information About You 1. Alien Registration Number (A-Number) (if any) 2. USCIS ELIS Account Number (if any) Your Full Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Other Names Used List all other names you have ever used, including maiden names, aliases, and nicknames. If you need extra space to complete this section, use the space provided in Part 10. Additional Information. 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Mailing Address NOTE: If you are outside of the United States, provide a U.S. mailing address if available. If a U.S. mailing address is not available, provide your mailing address abroad. 5.a. In Care Of Name 5.b. Street Number and Name 5.c. Apt. Ste. Flr. 5.d. City or Town 5.e. State 5.f. ZIP Code 5.g. Province 5.h. Postal Code 5.i. Country 6. Is your mailing address the same address where you currently live (physical address)? Y/N If your mailing address and the address where you currently live (physical address) are not the same, provide your current physical address in the next section. Physical Address 7.a. Street Number and Name 7.b. Apt. Ste. Flr. 7.c. City or Town 7.d. State 7.e. ZIP Code 7.f. Province 7.g. Postal Code 7.h. Country [Moved below to signature section] [Moved below to signature section] Other Information 8. U.S. Social Security Number (if any) 9. Gender M/F 10. Date of Birth (mm/dd/yyyy) 11. City or Town of Birth 12. Province of Birth (if applicable) 13. Country of Birth 14. Country of Citizenship or Nationality If you seek a visa and you were already interviewed by a U.S. Department of State (DOS) consular officer at a U.S. Embassy or U.S. Consulate, provide the information requested in Item Numbers 15.a. - 15.b. 15.a. DOS Consular Case Number (if available) 15.b. The location of the U.S. Embassy or U.S. Consulate where your visa application is being or will be made City Country 16.a. Are you filing this application after you have already filed Form I-485, Application to Register Permanent Residence or Adjust Status? Y/N 16.b. If you answered “Yes” to Item Number 16.a., provide the USCIS Receipt Number for your Form I-485. 17.a. Are you filing this application after you have already filed Form I-821, Application for Temporary Protected Status? Y/N 17.b. If you answered “Yes” to Item Number 17.a., provide the USCIS Receipt Number for your Form I-821, if any. [Delete.] [Delete.] 18.a. Have you previously filed Form I-212, Application for Permission to Reapply for Admission into the United States After Deportation or Removal? Y/N 18.b. If you answered “Yes” to Item Number 18.a., provide the USCIS Receipt Number for your Form I-212, if any. 18.c. Where did you file your application (for example, USCIS Office, U.S. Port-of-Entry, Immigration Court)? 18.d. Date Filed (mm/dd/yyyy) 19. Are you submitting Form I-212 along with this application? Y/N
New		Part 2. U.S. Entry Information Provide information for your previous periods of stay in the United States, beginning with your most recent arrival date. NOTE: If you need extra space to complete this section, use the space provided in Part 10. Additional Information. 1.a. Date you entered the U.S. (mm/dd/yyyy) 1.b. Immigration status at the time of your entry into the U.S. 1.c. Location at which you entered the U.S. 1.d. U.S. city or town where you lived 2.a. Date you entered the U.S. (mm/dd/yyyy) 2.b. Date you departed the U.S. (mm/dd/yyyy) 2.c. Immigration status at the time of your reentry into the U.S. 2.d. Location at which you entered the U.S. 2.e. U.S. city or town where you lived
NEW		Part 3. Biographic Information (for USCIS Applicants only) 1.  Ethnicity (Select only one box) __ Hispanic or Latino __ Not Hispanic or Latino 2.  Race (Select all applicable boxes) __ White __ Asian __ Black or African American __ American Indian or Alaska Native __ Native Hawaiian or Other Pacific Islander 3.  Height  Feet__ Inches __ 4.  Weight    Pounds _ ­_ _ 5.  Eye Color (Select only one box) __ Black __ Blue __ Brown __ Gray __ Green __ Hazel __ Maroon __ Pink __ Unknown/Other 6.  Hair Color (Select only one box) __ Bald (No hair) __ Black __ Blond __ Brown __ Gray __ Red __ Sandy __ White __ Unknown/Other
Page 2-4, Reason(s) for Inadmissibility	Reason(s) for Inadmissibility 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… 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. I have a communicable disease of public health significance, as per HHS regulations (see instructions). 15. 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). 16. I seek an exemption from the vaccination requirement because it is against my religious beliefs or moral convictions (see instructions). 17. I have been involved in a crime of moral turpitude (other than a purely political offense) (see instructions). 18. 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). 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). 29. I have been ordered removed, or… being admitted (see instructions for NACARA, HRIFA, and the instructions for approved VAWA self-petitioners only. Other applicants, file Form I-212). 30. Other (specify)….. B. I am applying for adjustment of status… because: (see instructions) 31. Specify C. I am applying for TPS and I believe that I am inadmissible because: (see instructions) Check all that apply 32. I have a communicable disease of public health significance. (A list of communicable diseases of public health significance can be found in the instructions). 33. I have or I had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated… 34. 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 have been a drug abuser or drug addict as described Department of Health and Human Services Regulations. See 42 CFR Part 34. 36. I have…. 37. I have…. 38. I am…. 39. I did not attend…. 40. I practice polygamy. 41. I have…. 42. I have…. 43. I was…. 44. I am a former United States citizen… 45. I tried to obtain a visa, other documentation, or admission into the United States or other… 46. I falsely…. 47. I have…. 48. I am…. 49. I have…. 50. Other (specify) Statement from Applicant In the space provided in number 51, describe…. 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. Your statement must also explain… If your application requires the showing… 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… NOTE: You should include… NOTE: If you require more space to complete your statement, use the space provided in Part 6. 51. ____ 52. a. City or Town…	Part 4. Reasons for Inadmissibility Mark all of the following grounds that you believe, according to the best of your knowledge, or that you were told, apply to you. Only mark the applicable grounds listed under the immigration benefit you are seeking. [Delete.] If you were ever arrested or convicted, provide the disposition (outcome) for all arrests or convictions (for example, dismissed from the appropriate authority). You also will be required to provide certified court records or dispositions for all convictions. If you are seeking a waiver of inadmissibility because you have a Class A Tuberculosis condition (as defined by U.S. Department of Health and Human Services (HHS) regulations), you must complete Part 11. of this application. If you are seeking a waiver of inadmissibility because you have a history of physical or mental disorders, you must attach the information requested in the instructions. Section A [subheader] I am an applicant for an immigrant visa or adjustment of status (other than based on T nonimmigrant status or based on classification as a Special Immigrant Juvenile, see Section B below), or for K or V nonimmigrant status, and I believe or I was told that I am inadmissible because (review the form instructions for a detailed explanation of the individual grounds of inadmissibility listed below): Select all grounds that you believe apply to you. 1. I have a communicable disease of public health significance. (A list of communicable diseases of public health significance can be found in the application instructions.) 2. I seek an exemption from the vaccination requirement because vaccinations are against my religious beliefs or moral convictions. 3. I have or had a physical or mental disorder and behavior (or 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. 4. I have been involved in a crime of moral turpitude (other than a purely political offense). 5. I have been involved in a controlled substance violation according to the laws and regulations of any state, the United States, or a foreign country related to a single offense of simple possession of 30 grams or less of marijuana. 6. I have been convicted of two or more offenses (other than purely political offenses), for which the combined sentences to confinement were five years or more. 7. I am coming to the U.S. to engage in prostitution or, in the past 10 years, I have engaged in prostitution (including receiving the proceeds of, in full or in part), procurement of prostitution, or I continue to engage in prostitution or procurement of prostitution. 8. In the past 10 years, I have (either directly or indirectly) procured, attempted to procure, or to import prostitutes or persons for the purpose of prostitution. 9. I came to the United States or I am coming to the United States to engage in any other unlawful commercialized vice whether or not it is related to prostitution. 10. I have been involved in serious criminal activity and have asserted immunity from prosecution. 11. 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. 12. I have sought to procure an immigration benefit by fraud or by concealing or misrepresenting a material fact (immigration fraud or misrepresentation). 13. I have been engaged in alien smuggling. 14. I am subject to a civil penalty because I was the subject of a final order for violation of the Immigration and Nationality Act (INA) section 274C. 15. 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 one year or more, respectively, and subsequently departed the United States. 16. I was previously removed from the United States. (See instructions for Nicaraguan Adjustment and Central American Relief Act (NACARA) and Haitian Refugee Immigration Fairness Act (HRIFA) applicants only. All other applicants file Form I-212.) 17. I have been ordered removed or… being admitted. (See instructions for NACARA, HRIFA, and the instructions for approved Violence Against Women Act (VAWA) self-petitioners only. Other applicants file Form I-212.) 18. Other (specify): Section B [subheader] I am applying for adjustment of status based on a valid T nonimmigrant status or based on classification as a Special Immigrant Juvenile and I believe or I was told that I am inadmissible because: 19. Specify (Review the application instructions for a detailed explanation of the individual grounds of inadmissibility related to your application.) Section C [subheader] I am applying for TPS and I believe or I was told that I am inadmissible because: Select all grounds that you believe, according to the best of your knowledge, or that you were told apply to you. 20. I have a communicable disease of public health significance. (A list of communicable diseases of public health significance can be found in the application instructions.) 21. I have or had a physical or mental disorder and behavior (or a history of behavior that is likely to recur) associated… 22. I am or have been a drug abuser or drug addict as described in U.S. Department of Health and Human Services (HHS) Regulations. See 42 CFR Part 34. 23. I have been involved in a controlled substance violation according to the laws and regulations of any state, the United States, or a foreign country related to a single offense of simple possession of 30 grams or less of marijuana. 24. I am coming to the U.S. to engage in prostitution or, in the past 10 years, I have engaged in prostitution (including receiving the proceeds of, in full or in part), procurement of prostitution, or I continue to engage in prostitution or procurement of prostitution. 25. In the past 10 years, I have (either directly or indirectly), procured, attempted to procure, or to import prostitutes or persons for the purpose of prostitution. 26. I came to the United States or I am coming to the United States to engage in any other unlawful commercialized vice, whether or not it is related to prostitution. 27. I have been involved in serious criminal activity and have asserted immunity from prosecution. 28. I did not attend or did not remain at a removal proceeding to determine my inadmissibility or deportability. 29. I have sought to procure an immigration benefit by fraud or by concealing or misrepresenting a material fact (immigration fraud or misrepresentation). 30. I falsely represented myself as a U.S. citizen. 31. I have been engaged in alien smuggling. 32. I am subject to a civil penalty because I have been the subject of a final order for violation of INA section 274C. 33. I am ineligible for U.S. citizenship because I departed from or remained outside the United States to avoid or evade training or service in the armed forces in a time of war or national emergency. 34. I have practiced polygamy since I entered the United States or I intend to practice polygamy in the United States. 35. 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. 36. 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 person granted custody. 37. I was an unlawful voter who voted in violation of a Federal, state, or local constitutional provision, statute, ordinance, or regulation. 38. I am a former U.S. citizen who renounced my citizenship in order to avoid taxation by the United States. 39. Other (specify): Your Inadmissibility Statement In the space provided in Item Number 40., provide a statement and a full explanation of the acts, convictions, and/or medical conditions that you believe 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 even if the information is also in the documents that you submit with your application. [Delete.] [Delete.] [Delete.] If you need extra space to complete your statement, use the space provided in Part 10. Additional Information or attach a separate letter. If you include separate letter, indicate in Item Number 40. that you are attaching a letter. 40. ____ [Delete.]
Page 5, Part 2. Information About Relative Through Whom Applicant Claims Eligibility, Where Applicable To assist the officers in searching for the Qualifying Family member, especially when family members have the same name.	Part 2. Information About Relative Through Whom Applicant Claims Eligibility, Where Applicable 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name … 2.e. Zip Code 2.f. Postal Code 2.g. Province Other Information 3. Daytime Phone Number Extension 4. E-mail Address (if any) 5. Relationship to Applicant 6. Immigration Status 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.	Part 5. Information About Your Qualifying Relatives Provide information for your U.S. citizen, lawful permanent resident through whom you are eligible to submit this application. In Item Number 9., provide a statement explaining the extreme hardship that you or your qualifying relative (U.S. citizen, lawful permanent resident, or other qualified parent or child) has or will experience if you are refused the immigration benefit you are seeking. [ ] Select here if you are a VAWA self-petitioner and would like to claim extreme hardship to yourself. (If you are only claiming extreme hardship for yourself, you can skip to Item Number 9. If you have additional qualifying relatives to whom you would like to claim extreme hardship, provide their information below.) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name … 2.e. ZIP Code 2.f. Province 2.g. Postal Code Contact Information 3. Daytime Telephone Number (if any) [delete extension.] 4. Email Address (if any) Other Information [Moved to Contact Information.] [Moved to Contact Information.] 5. What is your relative’s relationship to you? 6. What is your relative’s immigration status? 7. Relative’s A-Number (if any) 8. Date of Birth (mm/dd/yyyy) Select this box if you have additional relatives through whom you claim eligibility and go to Part 10. Additional Information to provide the same information as requested in Part 5., Item Numbers 1.a. - 8. Statement from Applicant (Extreme Hardship) [subheader] In the space provided below, explain the extreme hardship that your qualifying relative (or yourself if you are a VAWA self-petitioner) would experience if you are refused the immigration benefit you are seeking. For more information on extreme hardship, see the application instructions. If you need extra space to complete you statement, use the space provided in Part 10. Additional Information or attach a separate letter. Indicate in Item Number 9. if you are attaching a separate letter. The letter must be submitted at the same time as your Form I-601 application. 9. ________________________________ __________________________________
Page 6, Information About Applicant’s Other Relatives in the United States	Part 3. Information About Applicant’s Other Relatives In the United States 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name … 2.e. Zip Code 2.f. Postal Code 2.g. Province Other Information 3. Daytime Phone Number Extension 4. E-mail Address (if any) 5. Relationship to Applicant 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.	Part 6. Information About Your Other Relatives with Ties to the United States Provide information for any other U.S. citizen, lawful permanent resident, or any other family members you would like considered in deciding your case. In the space provided in Item Number 9., include a statement explaining why you believe your application should be approved as a matter of discretion, with the favorable factors outweighing the unfavorable factors in your case. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name … 2.e. ZIP Code 2.f. Province 2.g. Postal Code 2.h. Country Contact Information 3. Daytime Telephone Number (if any) [delete extension.] 4. Email Address (if any) Other Information [Moved to Contact Information.] [Moved to Contact Information.] 5. What is your relative’s relationship to you? 6. What is your relative’s immigration status? 7. Relative’s A-Number (if any) 8. Date of Birth (mm/dd/yyyy) Select this box if you have any other relatives with ties to the United States and go to Part 10. Additional Information to provide the same information as requested in Part 6., Item Numbers 1.a. - 8. Statement from Applicant (Discretion) [subheader] In the space provided below, explain why you believe your application should be approved as a matter of discretion, with the favorable outweighing the unfavorable factors in your case. For more information on discretion, see the application instructions. If you need extra space to complete you statement, use the space provided in Part 10. Additional Information or attach a separate letter. Indicate in Item Number 9. if you are attaching a separate letter. The letter must be submitted at the same time as your Form I-601 application. 9. ________________________________ __________________________________
Page 6, Signature of Applicant	Part 4. Signature of Applicant I certify…… I furthermore authorize….. 1.a. Signature of Applicant 1.b. Date of Signature	[NEW REVISED SECTION] Part 7. Applicant’s Statement, Contact Information, Acknowledgement of Appointment at USCIS Application Support Center, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-601 Instructions before completing this part. Applicant’s Statement [subheader] NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. I can read and understand English, and have read and understand every question and instruction on this application, as well as my answer to every question. I have read and understand the Acknowledgement of Appointment at USCIS Application Support Center. 1.b. The interpreter named in Part 8. has also read to me every question and instruction on this application, as well as my answer to every question, in [Fillable Field], a language in which I am fluent. I understand every question and instruction on this application as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above. The interpreter named in Part 8. has also read the Acknowledgement of Appointment at USCIS Application Support Center to me, in the language in which I am fluent, and I understand this Application Support Center (ASC) Acknowledgement as read to me by my interpreter. 2. I have requested the services of and consented to [Fillable Field], who is/is not an attorney or accredited representative, preparing this application for me. This person who assisted me in preparing my application has reviewed the Acknowledgement of Appointment at USCIS Application Support Center with me, and I understand the ASC Acknowledgement. Applicant’s Contact Information [sub header] 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) Acknowledgement of Appointment at USCIS Application Support Center [subheader] I, [Auto-populate Field with Applicant’s Full Name], understand that the purpose of a USCIS ASC appointment is for me to provide fingerprints, photograph, and/or signature and to re-affirm that all of the information in my application is complete, true, and correct and was provided by me. I understand that I will sign my name to the following declaration which USCIS will display to me at the time I provide my fingerprints, photograph, and/or signature during my ASC appointment. By signing here, I declare under penalty of perjury that I have reviewed and understand my application, as identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with my application that I (or my attorney or accredited representative) filed with USCIS, and that all of the information in these materials is complete, true, and correct. I also understand that when I sign my name, provide my fingerprints, and am photographed at the USCIS ASC, I will be re-affirming that I willingly submit this application; I have reviewed the contents of this application; all of the information in my application and all supporting documents submitted with my application were provided by me and are complete, true, and correct; and if I was assisted in completing this application, the person assisting me also reviewed this Acknowledgement of Appointment at USCIS Application Support Center with me. Applicant’s Certification [subheader] Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS or the adjudicating agency may require that I submit original documents to USCIS or the adjudicating agency at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS or the agency adjudicating my application may need to determine my eligibility for the immigration benefit that I seek. I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. Applicant’s Signature [sub header] 6.a. Applicant’s Signature 6.b. Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the instructions, USCIS or the adjudicating agency may deny your application.
		Part 8. Interpreter’s Contact Information , Certification, and Signature Provide the following information about the interpreter: Interpreter’s Full Name [sub header] 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter’s Mailing Address [sub header] 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Interpreter’s Contact Information [sub header] 4. Interpreter's Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification [sub header] I certify that: I am fluent in English and [Fillable Field], which is the same language provided in Part 7., Item Number 1.b.; and I have read to this applicant every question and instruction on this application, as well as the answer to every question, in the language provided in Part 7., Item Number 1.b. I have read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant in the same language provided in Part 7., Item Number 1.b.; The applicant has informed me that he or she understands every instruction and question on the application, as well as the answer to every question, and the applicant verified the accuracy of every answer; and The applicant has also informed me that he or she understands the ASC Acknowledgement and that by appearing for a USCIS ASC biometric services appointment and providing his or her fingerprints, photograph, and/or signature, he or she is re-affirming that the contents of this application and all supporting documentation are complete, true, and correct. Interpreter’s Signature [sub header] 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy)
Page 6, Part 5. Signature of Person Preparing This Application, If Other Than the Applicant	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 [Sub-header] Provide the following information concerning the preparer: 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2.a. Preparer’s Business or Organization Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province (if any) 3.g. Postal Code (if any) 3. h. Country Preparer’s Contact Information 4. Preparer’s Daytime Phone Number 5. Preparer’s E-mail Address (if any) Preparer’s Declaration 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. 7.a. Signature of Preparer 7.b. Date of Signature (mm/dd/yyyy)	Part 9. Contact Information, Statement, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant Provide the following information about the preparer: Preparer’s Full Name 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Preparer’s Contact Information [sub-header] 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number 6. Preparer’s Email Address (if any) Preparer’s Statement [sub-header] 7.a. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant’s consent. 7.b. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you must submit a completed Form G-28, Notice of Attorney or Accredited Representative, or G-28I, Notice of Entry of Appearance as Attorney in Matters Outside the Geographical Confines of the United States, with this application. Preparer’s Certification [sub-header] By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this application on behalf of, at the request of, and with the express consent of the applicant. I completed this application based only on responses the applicant provided to me. After completing the application, I reviewed it and all of the applicant’s responses with the applicant, who agreed with every answer on the application. If the applicant supplied additional information concerning a question on the application, I recorded it on the application. I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant and the applicant has informed me that he or she understands the ASC Acknowledgement. Preparer’s Signature [sub-header] 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy)
Page 7, Part 6. Additional Information	Part 6. Additional Information If you require more space to complete an item, please use this space below. In order to assist us in reviewing your response, you must identify the Part Number and Item Number.	Part 10. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Include your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Family Name (Last Name) [autofill] 1.b. Given Name (First Name) [autofill] 1.c. Middle Name [autofill] 2. A-Number [autofill] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Narrative space] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Narrative space] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Narrative space] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Narrative space] 7.a. Applicant’s Signature 7.b. Date of Signature (mm/dd/yyyy)
Pages 8-9, To Be Completed for Applicants With Class A Tuberculosis Condition (As Per HHS Regulations)	To Be Completed for Applicants With Class A Tuberculosis Condition (As Per HHS Regulations) Section A. Statement by Applicant Upon admission to the United States I will: 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; C. Submit to such examinations, treatment, isolation, and medical regimen as may be required; and D. Remain under the prescribed treatment or observation, whether on inpatient or outpatient basis, until discharged. 1.a. Signature of Applicant 1.b. Date of Signature (mm/dd/yyyy) 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. 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. 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, address, and phone number of the health department below): 1.a. City Health Department 1.b. County Health Department 2.a. Name of Health Department (Type or print in black ink) 2.b. Street Number and Name 2.c. Apt. Ste. Flr. 2.d. City or Town 2.e. State 2.f. Zip Code 3.a Signature of Physician 3.b. Date of Signature (mm/dd/yyyy) 3.c. Printed Name of Physician 3.d. Daytime Phone Number/Extension 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. Ste. Flr. 1.c. City or Town 1.d. State 1.e. Zip Code 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: 1.a. Signature of State Health Department Official 1.b. Date of Signature (mm/dd/yyyy) 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 2.e. State 2.f. Zip Code 2.g. Daytime Telephone Number/Extension 2.h. E-mail Address (if any) 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).	[NEW HEADER] Part 11. Statement for Applicants With a Class A Tuberculosis Condition (As Defined By HHS Regulations) To be completed for applicants with a Class A Tuberculosis Condition (as defined by HHS Regulations). Statement by Applicant Upon admission to the United States, I will go directly to the health department named in the section below; present all X-rays used in the visa medical examination to substantiate diagnosis; submit to such examinations, treatment, isolation, and medical regimen as may be required; and remain under the prescribed treatment or observation, whether on an inpatient or outpatient basis, until discharged. 1.a. Signature of Applicant 1.b. Date of Signature (mm/dd/yyyy) 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. I agree to supply any treatment or observation necessary for the proper management and continued care of the alien's tuberculosis condition. Within 30 days of the alien reporting for care, I agree to submit a summary of my initial evaluation of the alien’s condition, indicate presumptive diagnosis, and provide test results and plans for future care of the alien to the State Health Department Official named in the Endorsement of State Health Department Official section and to the Division of Global Migration and Quarantine (E03), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia 30333. [delete] I also agree to report the alien if the alien has not reported within 30 days after receiving notice from the Division of Global Migration and Quarantine, CDC. 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 (select the appropriate box and give the complete name, address, certification, and contact information of the health department): 2.a. City Health Department 2.b. County Health Department 3. Name of Health Department Physical Address [subheader] 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.e. ZIP Code Physician’s Certification [subheader] 5.a. Signature of Physician 5.b. Date of Signature (mm/dd/yyyy) 5.c. Physician’s Family Name (Last Name) 5.d. Physician’s Given Name (First Name) Physician’s Contact Information [subheader] 6. Daytime Telephone Number [delete extension.] 7. Email Address (if any) 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 Statement by Local (City or County) Health Department and Endorsement of State Health Department Official sections. Provide the following information: Address where you (the sponsor) or the applicant plan to reside in the United States: 8.a. Street Number and Name 8.b. Apt. Ste. Flr. 8.c. City or Town 8.d. State 8.e. ZIP Code 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 the Statement by Local (City or County) Health Department section 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: 9.a. Signature of State Health Department Official 9.b. Date of Signature (mm/dd/yyyy) 10. Name of State Health Department Physical Address 11.b. Street Number and Name 11.c. Apt. Ste. Flr. 11.d. City or Town 11.e. State 11.f. ZIP Code Contact Information 12. Daytime Telephone Number [delete extension] 13. Email Address (if any) 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 the 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 INA section 237(a).

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