Form I-601 Application for Waiver of Grounds of Inadmissibility

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

Adjustment of Status

V Nonimmigrant

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

Resubmitted

Action Block

Relocated
Received
Sent

Benefits Category
Immigrant

OMB No. 1615-0029
Expires 03/31/2017

Draft Not for
Production
Initial
Receipt

Fee Stamp

For
USCIS
Use
Only

USCIS
Form I-601

TPS

K Nonimmigrant

To be completed
by an Attorney
or Accredited
Representative (if any).

212(a)(3)

212(a)(6)

212(a)(10)

212(a)(4)

212(a)(9)

Other

Select this box if
Form G-28 is
attached.

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS ELIS Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You

Mailing Address

1.

Alien Registration Number (A-Number) (if any)
► A-

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.

2.

USCIS ELIS Account Number (if any)
►

5.a. In Care Of Name

Your Full Name

5.b. Street Number
and Name

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

5.c.

3.c. Middle Name

Other Names Used

Apt.

Ste.

Flr.

5.d. City or Town

03/24/2015
5.e. State

5.f.

ZIP Code

5.g. Province

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.

5.h. Postal Code
5.i.

Country

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

6.

Is your mailing address the same address where you
currently live (physical address)?
Yes
No

4.c. Middle Name

Form I-601 03/18/15 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.

Page 1 of 13

Part 1. Information About You (continued)
Physical Address

Apt.

Ste.

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

Draft Not for
Production

16.b. If you answered "Yes" to Item Number 16.a., provide
the USCIS Receipt Number for your Form I-485.

7.a. Street Number
and Name
7.b.

►

Flr.

7.e. ZIP Code

17.a. Are you filing this application after you have already filed
Form I-821, Application for Temporary Protected Status?
Yes
No

17.b. If you answered "Yes" to Item Number 17.a., provide
the USCIS Receipt Number for your Form I-821, if any.

Province

►

7.g. Postal Code

18.a. Have you previously filed Form I-212, Application for
Permission to Reapply for Admission into the United
States After Deportation or Removal?
Yes
No

7.h. Country

18.b. If you answered "Yes" to Item Number 18.a., provide
the USCIS Receipt Number for your Form I-212, if any.

Other Information
8.

16.a. Are you filing this application after you have already filed
Form I-485, Application to Register Permanent Residence
or Adjust Status?
Yes
No

►

U.S. Social Security Number (if any)
►

9.

Gender

Male

10.

Date of Birth (mm/dd/yyyy)

11.

City or Town of Birth

12.

Province of Birth (if applicable)

18.c. Where did you file your application (for example, USCIS
Office, U.S. Port-of-Entry, Immigration Court)?

Female
18.d. Date Filed (mm/dd/yyyy)
19.

Are you submitting Form I-212 along with this application?
Yes
No

Part 2. U.S. Entry Information
13.

Country of Birth

Provide information for your previous periods of stay in the
United States, beginning with your most recent arrival date.

14.

Country of Citizenship or Nationality

NOTE: If you need extra space to complete this section, use
the space provided in Part 10. Additional Information.

03/24/2015

1.a. Date you entered the U.S. (mm/dd/yyyy)

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

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

City

Country

2.a. Date you entered the U.S. (mm/dd/yyyy)

2.b. Date you departed the U.S. (mm/dd/yyyy)

Form I-601 03/18/15 N

Page 2 of 13

Part 2. U.S. Entry Information (continued)
2.c. Immigration status at the time of your entry into the U.S.

2.d

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.

Draft Not for
Production

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.

Location at which you entered the U.S.

2.e. U.S. city or town where you lived

Section A

Part 3. Biographic Information (for USCIS
Applicant 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

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
application 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
Specific Instructions section of 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.

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
3.

Height

Feet

4.

Weight

Pounds

5.

Eye Color (Select only one box)

6.

Inches

Black

Blue

Brown

Gray

Green

Maroon

Pink

Hazel
Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Black
Gray
White

Blond
Red

03/24/2015
Unknown/
Other

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.

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.
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.

Form I-601 03/18/15 N

Page 3 of 13

Part 4. Reasons for Inadmissibility (continued)

Section B

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.

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:

10.

I have been involved in serious criminal activity and
have asserted immunity from prosecution.

19.

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).

Draft Not for
Production

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.

16.

17.

18.

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.
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.)
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. (See instructions for NACARA, HRIFA,
and the instructions for approved Violence Against
Women Act (VAWA) self-petitioners only. Other
applicants file Form I-212.)
Other (specify):

Form I-601 03/18/15 N

Specify (Review the application instructions for a
detailed explanation of the individual grounds of
inadmissibility related to your application.)

Section C

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 Specific
Instructions section of 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 with the disorder, which has posed or
may pose a threat to the property, safety, or welfare of
myself or others.

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 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.

03/24/2015
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.
Page 4 of 13

Part 4. Reasons for Inadmissibility (continued)
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):

40.

Draft Not for
Production

03/24/2015

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 or you were told 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.
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 a separate letter, indicate in Item
Number 39. that you are attaching a letter.

Form I-601 03/18/15 N

Page 5 of 13

Part 5. Information About Your Qualifying
Relatives

6.

What is your relative's immigration status?

Draft Not for
Production

Provide information for your U.S. citizen or 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.)

Relative's Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

7.

Relative's A-Number (if any)
► A-

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)

In the space provided below, explain the extreme hardship that
your qualifying relative (or yourself if you are a VAWA selfpetitioner) 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 your 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.

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

Apt.

Ste.

Flr.

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

2.e. ZIP Code

Province

2.g. Postal Code
2.h. Country

Contact Information
3.

4.

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.

03/24/2015

Daytime Telephone Number (if any)

Relative's Full Name

Email Address (if any)

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

Other Information
5.

Part 6. Information About Your Other Relatives
with Ties to the United States

1.c. Middle Name

What is your relative's relationship to you?

Form I-601 03/18/15 N

Page 6 of 13

Part 6. Information About Your Other Relatives
with Ties to the United States (continued)
Physical Address
2.a. Street Number
and Name
2.b.

Apt.

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

Province

2.g. Postal Code
2.h. Country

Statement from Applicant (Discretion)
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 your 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.

Draft Not for
Production

Ste.

Flr.

2.e. ZIP Code

Contact Information
3.

Daytime Telephone Number (if any)

4.

Email Address (if any)

9.

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.

Other Information
5.

What is your relative's relationship to you?

Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.

6.

What is your relative's immigration status?

7.

Relative's A-Number (if any)
► A-

8.

Date of Birth (mm/dd/yyyy)

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.

03/24/2015

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.

Form I-601 03/18/15 N

1.a.

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

,

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.

Page 7 of 13

Part 7. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature (continued)
2.

Applicant's Certification
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.

Draft Not for
Production

I have requested the services of and consented to

,

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
3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

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.
I certify, under penalty of perjury, that the information in my
application and any document submitted with my application
were provided by me and are complete, true, and correct.

Applicant's Signature
6.a. Applicant's Signature

5.

Applicant's Email Address (if any)
6.b. Date of Signature (mm/dd/yyyy)

Acknowledgement of Appointment at USCIS
Application Support Center
I,
,
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.

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
1.a. Interpreter's Family Name (Last Name)

03/24/2015

By signing here, I declare under penalty of perjury that I
have reviewed and understand my application, petition, or
request as identified by the receipt number displayed on the
screen above, and all supporting documents, applications,
petitions, or requests filed with my application, petition, or
request 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.

1.b. Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

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.
Form I-601 03/18/15 N

Page 8 of 13

Part 8. Interpreter's Contact Information,
Certification, and Signature (continued)

Interpreter's Signature
6.a. Interpreter's Signature

Draft Not for
Production

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

Apt.

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

Province

3.g. Postal Code
3.h. Country

6.b. Date of Signature (mm/dd/yyyy)

Ste.

Flr.

3.e. ZIP Code

Provide the following information about the preparer.

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

Interpreter's Contact Information
4.

Part 9. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant

1.b. Preparer's Given Name (First Name)

Interpreter's Daytime Telephone Number
2.

5.

Preparer's Business or Organization Name (if any)

Interpreter's Email Address (if any)

Preparer's Mailing Address
Interpreter's Certification

3.a. Street Number
and Name

I certify that:

3.b.

,
I am fluent in English and
which is the same language provided in Part 7., Item Number
1.b.;

Apt.

Ste.

Flr.

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

3.e. ZIP Code

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.; and

3.f.

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..

3.h. Country

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

Preparer's Contact Information

Province

03/24/2015

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.

Form I-601 03/18/15 N

3.g. Postal Code

4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

6.

Preparer's Email Address (if any)

Page 9 of 13

Part 9. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant (continued)

Draft Not for
Production

Preparer's Statement
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 Entry of Appearance
as 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
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
8.a. Preparer's Signature

03/24/2015

8.b. Date of Signature (mm/dd/yyyy)

Form I-601 03/18/15 N

Page 10 of 13

5.a. Page 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)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.c. Item Number

Draft Not for
Production
5.d.

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number
6.a. Page Number

6.b. Part Number

6.c. Item Number

3.d.
6.d.

4.a. Page Number

4.d.

03/24/2015

4.b. Part Number

4.c. Item Number

7.a. Applicant's Signature

7.b. Date of Signature (mm/dd/yyyy)

Form I-601 03/18/15 N

Page 11 of 13

Part 11. Statement for Applicants With a Class
A Tuberculosis Condition (As Defined By HHS
Regulations)

Physical Address
4.a. Street Number
and Name

Draft Not for
Production

To be completed for applicants with a Class A Tuberculosis
Condition (as defined by HHS Regulations).

4.b.

Apt.

Ste.

Flr.

4.c. City or Town

Statement by Applicant

Upon admission to the United States, I will go directly to the
health department named in the section below; present all Xrays 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

4.d. State

4.e. ZIP Code

Physician's Certification

5.a. Signature of Physician

5.b. Date of Signature (mm/dd/yyyy)

5.c. Physician's Family Name (Last Name)

1.b. Date of Signature (mm/dd/yyyy)

5.d. Physician's Given Name (First Name)

Statement by Local (City or County) Health
Department

Physician's Contact Information

NOTE: The physician at the local health department in the area
where the alien plans to reside should complete this statement.

6.

Daytime Telephone Number

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

7.

Email Address (if any)

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.

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.

03/24/2015

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.

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

Name of Health Department

Form I-601 03/18/15 N

Page 12 of 13

Part 11. Statement for Applicants With a Class
A Tuberculosis Condition (As Defined By HHS
Regulations) (continued)

Draft Not for
Production

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.a. Street Number
and Name
11.b.

Apt.

Ste.

Flr.

11.c. City or Town
11.d. State

11.e. ZIP Code

Contact Information

03/24/2015

12.

Daytime Telephone Number

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 our online
system, InfoPass, at infopass.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).

Form I-601 03/18/15 N

Page 13 of 13