Page 1-3, Part 1.
Information About Applicant
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[Page 1]
Part 1. Information About
Applicant
Provide the….
1. Alien Registration Number
(A-Number) (if applicable)
2. U.S. Social Security
Number (optional)…
Other Names Used…
Home Address (where
you physically reside)
6.a. Street Number and Name
6.b. Apt. Ste. Flr.
6.c. City or Town
6.d. State
6.e. Zip Code
Mailing Address (if
different from Home Address)
7.a. In Care Of Name
7.b. Street Number and Name
7.c. Apt. Ste. Flr.
7.d. City or Town
7.e. State
7.f. Zip Code
[Page 2]
Contact Information
8. Daytime Phone Number (if
any)
9. E-mail Address (if any)
Birth and Citizenship
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
Last Entry Into the United
States
15. Date of Entry
(mm/dd/yyyy)
16.a. Place or Port of Entry
(City or Town)
16.b. State
17. Immigration Status (at
the time of entry)
Previous Entries Into the
United States
Applicant was previously…
18.a. Place or Port
of Entry (City or Town)
18.b. State
19.a. Date From (mm/dd/yyyy)
19.b. Date To (mm/dd/yyyy)
20. Immigration Status (at
the time of entry)
21.a. Place or Port of Entry
(City or Town)
21.b. State
22.a. Date From (mm/dd/yyyy)
22.b. Date To (mm/dd/yyyy)
23. Immigration Status (at
the time of entry)
24. Are there previous
entries?
If “Yes,” include the
place of entry, dates, and immigration status for previous entries
in Part 5, Additional Information, of this form.
Immigration or Criminal
History
25. Are you currently in
removal proceedings (this includes being subject to a final
removal order or to a DHS order reinstating a prior removal
order)?
Note: If you
answered “No,” skim to Item Number 27.
Note: If your case
has been administratively closed, you are still “in removal
proceedings” until the Department of Justice, Executive
Office for Immigration Review (EOIR) terminates or dismisses your
case. However, you are eligible to apply for a provisional
unlawful presence waiver if EOIR has not placed your removal
proceedings back on EOIR's calendar to continue your removal
proceedings.
26. If you answered “Yes”
to Item Number 25., select the statement below that most
accurately describes your current situation:
I am in removal proceedings that are
administratively closed and have not been placed back on
EIOR’s calendar to continue my removal proceedings, at
the time of filing a Form I-601A.
Note: Provide a
copy of the administrative closure notice. You should seek
termination or dismissal of your removal proceedings before
you depart the United States if your application for a provisional
unlawful presence waiver is approved.
I am now subject to a final order of
removal, deportation, or exclusion, or to the reinstatement of a
prior removal order.
I am subject to a DHS order
reinstating a prior removal order.
I am currently in removal
proceedings that are not administratively closed, or I am
currently in removal proceedings that were administratively
closed, but my proceedings have been placed back on EOIR’s
calendar to continue my removal proceedings.
[Page 3]
27. Have you ever knowingly
and …
28. Have you ever knowingly
assisted….
29. Have you ever been
arrested, cited, or detained by a law enforcement officer
(including immigration and military officers)…
30. Have you ever been
charged….
Have you ever engaged in,
ordered, incited, assisted, or otherwise participated in any of
the following:
31.a. Acts involving torture,
genocide, or human trafficking?
31.b. Killing any person?
31.c. Severely injuring any person?
31.d. Any kind of sexual contact or
relations with any person who was being forced or threatened?
Note: If you
answered “Yes” to …..
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[Page 1]
Part 1. Information About You
Provide the….
1. Alien Registration Number
(A-Number) (if any)
2. U.S. Social Security
Number (if any)
3.
USCIS ELIS Account Number (if any)
Your
Full Name
4.a.
Family Name (Last Name)
4.b.
Given Name (First Name)
4.c.
Middle Name
Other Names Used (if
any)
5.a.
Family Name (Last Name)
5.b.
Given Name (First Name)
5.c.
Middle Name
6.a.
Family Name (Last Name)
6.b.
Given Name (First Name)
6.c.
Middle Name
[moved below]
Your
U.S. Mailing Address
7.a. In
Care Of Name
7.b.
Street Number and Name
7.c. Apt.
Ste. Flr.
7.d.
City or Town
7.e.
State
7.f.
ZIP Code
8.
Is your current physical address the same as your mailing
address? Y/N
If you
answered “No” to Item
Number 8., provide your physical
address in Item Numbers 9.a.
- 9.e.
Your
U.S. Physical Address
9.a.
Street Number and Name
9.b. Apt.
Ste. Flr.
9.c. City
or Town
9.d. State
9.e. ZIP
Code
[Delete]
[Moved to
Applicant signature section]
[Moved to
Applicant signature section]
Other
Information
10.
Date of Birth (mm/dd/yyyy)
11. Gender
Male/Female
[Page 2]
12.
City or Town of Birth
[Delete]
13.
Country of Birth
14.
Country of Citizenship or
Nationality
15.a.
Mother’s Family Name (Last
Name)
15.b.
Mother’s Given Name (First
Name)
16.a.
Father’s Family Name (Last
Name)
16.b.
Father’s Given Name (First
Name)
Your
Last Entry Into the United States
17.
Date of Entry (mm/dd/yyyy)
18.a.
Place or Port-of-Entry (City
or Town)
18.b.
State
19.
Immigration Status (at the time of entry)
Your
Previous Entries Into the United States
You were
previously…
20.a.
Place or Port-of-Entry
(City or Town)
20.b.
State
21.a.
From (mm/dd/yyyy)
21.b.
To (mm/dd/yyyy)
22.
Immigration Status (at the time of
entry)
23.a.
Place or Port of Entry (City or
Town)
23.b.
State
24.a. From
(mm/dd/yyyy)
24.b. To
(mm/dd/yyyy)
25.
Immigration Status (at the time
of entry)
26. Are
there other previous entries? Y/N
If you
answered “Yes” to Item
Number 26., include the
place of entry, dates, and your immigration
status at the time of entry for any
other prior entries in Part 9.
Additional Information
of this application.
Your
Immigration or Criminal History
27. Are
you currently in removal, exclusion, or
deportation proceedings? This
includes being subject to a final
order of removal, exclusion, or deportation or a Department of
Homeland Security (DHS) removal order that reinstates a prior
removal, exclusion, or deportation order.
[Delete]
NOTE: If your case has been
administratively closed, you are still "in removal
proceedings" until the Department of Justice's Executive
Office for Immigration Review (EOIR) terminates or dismisses your
case. However, you are eligible to apply for a provisional
unlawful presence waiver if EOIR has not placed your removal
proceedings back on EOIR's calendar in order
to continue your removal proceeding.
If you
answered “Yes” to Item Number 27.,
select the statement below that most accurately
describes your current situation. Y/N
28.a.
I am in removal, exclusion, or
deportation proceedings that are administratively closed
and, at the time of filing my Form I-601A,
have not been placed back on EIOR’s calendar
to continue my removal, exclusion, or
deportation proceedings.
NOTE:
Provide a copy of the
administrative closure order. Also, if U.S. Citizenship and
Immigration Services (USCIS) approves your provisional unlawful
presence waiver, you should seek termination or dismissal of your
removal, exclusion, or deportation proceedings before
you depart the United States for your immigrant visa interview.
28.b.
I am subject to
a final order of removal, exclusion,
or deportation.
28.c.
I am subject to a DHS order
that reinstates
a prior removal, exclusion, or deportation
order seeking my removal, exclusion, or
deportation from the United States.
[Page 3]
28.d.
I am currently in removal,
exclusion, or deportation proceedings that are not
administratively closed or in
removal, exclusion, or deportation
proceedings that were administratively closed, but EOIR
has placed my proceedings back on its calendar in order to
continue them.
28.e.
I am subject to a judicial order of removal issued by a Federal
Court.
Answer Item
Numbers 29. - 35. If you answer
“Yes” to any question in Item
Numbers 29. - 35., you may be
ineligible for a provisional unlawful presence waiver if USCIS has
reason to believe that you may be subject to grounds of
inadmissibility, other than unlawful presence under INA section
212(a)(9)(B)(i)(I) or (II) at the time of your immigrant visa
interview with a Department of State (DOS) consular officer. For
each “Yes” response for Item
Numbers 29. - 35., provide the
location and date of the event and a brief description in Part
9. Additional Information. For
Item Number 31.,
if you were not charged with any crime or offense, provide a
statement or other documentation from the arresting authority or
prosecutor’s office to show that you were not charged with
any crime or offense. If you answer “Yes” to Item
Number 32., you must provide all
related court dispositions.
29.
Have you EVER knowingly
and …
30.
Have you EVER knowingly
assisted….
31.
Have you EVER been arrested,
cited, or detained by a law enforcement officer (including
immigration and military officers)…
32.
Have you EVER been charged….
33.
Have you EVER
trafficked in or are you NOW
trafficking in any controlled substance?
34. Are
you NOW
or have you EVER knowingly
assisted, abetted, conspired, or colluded with others in the
unlawful trafficking of any controlled substance?
35.
Are you NOW
or have you EVER
been engaged in prostitution?
Answer Item
Numbers 36.a. - 42. If you
answer “Yes” to any
question in
Item Numbers 36.a.
- 42., you may be ineligible for
a provisional unlawful presence waiver if USCIS has reason to
believe that you may be subject to grounds of inadmissibility
other than unlawful presence under INA section 212(a)(9)(B)(i)(I)
or (II) at the time of your immigrant visa interview with a DOS
consular officer. For each “Yes” response for Item
Numbers 36.a. - 42.,
provide a complete explanation in
Part 9. Additional Information.
Have you EVER
ordered, incited, called for, committed, assisted, helped with, or
otherwise participated in any of the following:
36.a.
Acts involving torture or genocide?
Y/N
36.b.
Killing any person? Y/N
36.c.
Intentionally and severely injuring any person? Y/N
36.d.
Engaging in any kind of sexual contact or relations with
any person who was being forced or
threatened to participate or through use of threat? Y/N
36.e.
Limiting or denying any person’s ability to exercise
religious beliefs? Y/N
[Delete.]
Have you EVER:
37.a.
Served in, been a member of, assisted in, or participated in any
military unit, paramilitary unit, police unit, self-defense unit,
vigilante unit, rebel group, guerilla group, militia, or insurgent
organization? Y/N
37.b.
Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons? Y/N
38.
Have you EVER
been a member of, assisted in, or participated in any group, unit,
or organization of any kind in which you or other persons used any
type of weapon against any person or threatened to do so? Y/N
39.
Have you EVER
assisted or participated in selling or providing weapons to any
person who to your knowledge used them against another person, or
in transporting weapons to any person who to your knowledge used
them against another person? Y/N
40.
Have you EVER
received any type of military, paramilitary, or weapons training?
Y/N
41.
Have you EVER
recruited, enlisted, conscripted, or used any person under 15
years of age to serve in or help an armed force or group? Y/N
42.
Have you EVER
used any person under 15 years of age to take part in hostilities,
or to help or provide services to people in combat? Y/N
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Page 5, Part 6.
Signature of Applicant
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Part 6. Signature of Applicant
(Read the Penalties section of the instructions before
you sign this application.)
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 provisional unlawful
presence waiver.
I
further 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 the U.S.
immigration laws.
1.a.
Signature of
Applicant
1.b.
Date of
Signature (mm/dd/yyyy)
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[Page 6]
Part 6. 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-601A Instructions before completing this
part. You must
file Form I-601A while in the United States.
Applicant's Statement
[subheader]
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 the Acknowledgement of
Appointment at USCIS Application Support Center.
1.b.
The interpreter named in Part 7.
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 7.
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
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
I, [Applicant
Name], understand that the purpose of a USCIS
ASC appointment is for me to provide
my 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, 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.
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
Copies of any
documents I have submitted are exact photocopies of unaltered,
original documents, and I understand that USCIS may require that I
submit original documents to USCIS at a later date. Furthermore,
I authorize the release of any information from any
and all of my records that USCIS 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.
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
6.b.
Date of Signature (mm/dd/yyyy)
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Page 6, Part 8.
Signature of Interpreter
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Part 8. Signature of Interpreter
Interpreter's
Information
3.a.
Interpreter's
Family Name (Last
Name)
3.b.
Interpreter's
Given Name (First
Name)
1.
Language Used
I
certify that I am fluent in English and the language above. I
further certify that I have read each and every question and
instruction on this form, as well as the answer to each question,
to this applicant in the above-mentioned language, and that the
applicant has informed me that he or she has understood each and
every instruction and question of the form, as well as the answer
to each question on the form.
2.a.
Signature of
Interpreter
2.b.
Date of
Signature (mm/dd/yyyy)
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[Page 6]
Part
7. Interpreter’s Contact Information, Certification, and
Signature
Provide the
following information concerning the interpreter.
Interpreter’s Full
Name
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)
[Page 7]
Interpreter’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
Interpreter’s
Contact Information
4.
Interpreter’s Daytime Telephone Number
5.
Interpreter’s Email Address (if
any)
Interpreter’s
Certification
I certify
that:
I am
fluent in English and [Fillable Field] which
is the same language provided in Part
6., Item
Number 1.b.;
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
6., Item
Number 1.b.; and
I
have read the Acknowledgement of
Appointment at USCIS Application Support Center
to the applicant in the same language provided in Part
6., 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
6.a.
Interpreter’s Signature
6.b.
Date of Signature (mm/dd/yyyy)
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Pages 5-6, Part 7.
Signature and Contact Information of Person Preparing This
Application (if other than the applicant)
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[Page 5]
Part 7. Signature and Contact
Information of Person Preparing This Application (if other
than the applicant)
NOTE:
If you are an
attorney or BIA-accredited representative, you must submit a
completed Form G-28, Notice of Entry of Appearance as Attorney or
Accredited Representative, along with this form.
1. Attorney or
Representative: In the event of a Request for Evidence (RFE), may
USCIS contact you by e-mail?
Preparer's
Full Name
Provide
the following information concerning the preparer:
2.a.
Preparer's
Family Name (Last
Name)
2.b.
Preparer's Given
Name (First Name)
3.
Preparer's
Business or Organization Name
[Page
6]
Preparer's
Mailing 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
Preparer's
Contact Information
5.
Preparer's
Daytime Phone Number
Extension
6.
Preparer's
E-mail Address (if
any)
Declaration
of Preparer
I
declare that this document was prepared by me at the request of
the applicant, 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 or provided responses for the
applicant.
7.a.
Signature of
Preparer
7.b.
Date of
Signature (mm/dd/yyyy)
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[Page 7]
Part 8.
Contact Information, Declaration, and Signature of the Person
Preparing this Application, If Other Than the Applicant
[Deleted]
[Deleted]
Provide the following information
concerning 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
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
[Page 8]
Preparer’s Contact
Information
4.
Preparer’s Daytime Telephone Number
[Deleted]
5.
Preparer’s Fax Number (if any)
6. Preparer’s Email
Address (if any)
[Page 8]
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, 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 this 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
8.b.
Date of Signature (mm/dd/yyyy)
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