Fillable Printable Form I-191
Fillable Printable Form I-191
Form I-191
Form I-191 12/23/16 N Page 1 of 17
To be completed by an
attorney or accredited
representative (if any).
Application for Relief Under Former Section 212(c)
of the Immigration and Nationality Act (INA)
Department of Homeland Security
U.S. Citizenship and Immigration Services
For
USCIS
Use
Only
USCIS
Form I-191
OMB No. 1615-0016
Expires 09/30/2018
Part 1. Information About You
START HERE - Type or print in black ink.►
Family Name (Last Name) Given Name (First Name) Middle Name
Your Full Name (do not provide a nickname)1.
Middle NameGiven Name (First Name)Family Name (Last Name)
Other Names Used2.
3. 4.Date of Birth (mm/dd/yyyy)
5.
Place of Birth
City/Town/Village of Birth
Country of Birth
State/Province of Birth
Alien Registration Number (A-Number) (if any)
►
A-
I am applying for permission to return to the United States under the authority contained in former section 212
(c)
of the Immigration
and Nationality Act (INA).
6.
Action BlockDate Fee Stamp
Attorney State Bar Number
(if applicable)
Select this box if
Form G-28 is
attached.
Attorney or Accredited Representative
USCIS Online Account Number (if any)
USCIS Online Account Number (if any)
►
RECEIVED
COMPLETEDRETD/TRANS OUT
TRANS IN
List all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this
section, use the space provided in Part 12. Additional Information.
7. Country of Citizenship or Nationality
Form I-191 12/23/16 N Page 2 of 17
Admission With an Immigrant Visa at a Port-of-Entry
Adjustment of Status While in the United States
Port-of-Entry, If Known
USCIS Office
Means of Transportation
Part 1. Information About You (continued)
10.
11.
Information About When and How You Became a Lawful Permanent Resident (LPR)
A.
B.
(mm/dd/yyyy)
Date When You Obtained Your LPR Status
You Obtained Your LPR Status Through (select only one)
In Care Of Name (if any)
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Mailing Address 8.
9. Physical Address
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
Postal Code CountryProvince
Passport Number Used at Last Entry Travel Document Number Used at Last Entry12.
13. Country of Issuance for Passport or Travel Document 14. Expiration Date of This Passport or Travel Document
(mm/dd/yyyy)
Form I-191 12/23/16 N Page 3 of 17
Purpose of Trips
Place or Port-of-Entry
Date of Entry
(mm/dd/yyyy)
Means of Transportation
Returned To The United States
Part 1. Information About You (continued)
Information About Your Departures From and Returns To the United States
Since being admitted as an LPR, you have departed from and returned to the United States as follows:
15.
Departed From The United States
Means of Transportation
Date of Departure
(mm/dd/yyyy)
Place or Port-of-Departure
Form I-191 12/23/16 N Page 4 of 17
Part 3. Information About Your Criminal Convictions
Criminal Conviction 1
The information you provide below relates to the criminal convictions for which you are seeking relief under former section 212(c) of
the Immigration and Nationality Act.
A.
1.
D.
Conviction Entered
If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy)
E.
Court Case Number
Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific
offense.)
Sentence, Probation, or Other Punishment ImposedH.
G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide
each separate citation.)
F.
C. Location of Court
Town or City State
B.Date (mm/dd/yyyy)
Based on Guilty or No Contest Plea
After Trial
Name of Court
Part 2. Biographic Information
Hair Color (Select only one box)
6.
Black
BlondBald (No
hair)
Brown
RedGray
Unknown/
Other
Sandy White
Not Hispanic or LatinoHispanic or Latino
Ethnicity (Select only one box)1.
American Indian or
Alaska Native
Race (Select all applicable boxes)
2.
Native Hawaiian or
Other Pacific Islander
Black or African
American
Asian
White
Feet InchesHeight3.
Weight 4. Pounds
5. Eye Color (Select only one box)
Blue GreenBrown Hazel MaroonGray Pink Unknown/OtherBlack
Form I-191 12/23/16 N Page 5 of 17
Criminal Conviction 3
NOTE: If you were convicted more than three times, include the information for each additional conviction in Part 12. Additional
Information.
Part 3. Information About Your Criminal Convictions (continued)
A.
3.
D.
Conviction Entered
If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy)
E.
Court Case Number
Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific
offense.)
Sentence, Probation, or Other Punishment ImposedH.
G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide
each separate citation.)
F.
C. Location of Court
Town or City State
B.Date (mm/dd/yyyy)
Based on Guilty or No Contest Plea
After Trial
Name of Court
Criminal Conviction 2
A.
2.
D.
Conviction Entered
If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy)
E.
Court Case Number
Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific
offense.)
Sentence, Probation, or Other Punishment ImposedH.
G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide
each separate citation.)
F.
C. Location of Court
Town or City State
B.Date (mm/dd/yyyy)
Based on Guilty or No Contest Plea
After Trial
Name of Court
Form I-191 12/23/16 N Page 6 of 17
Part 4. Information About Your Residence
From (mm/dd/yyyy)
Physical Address 33.
To (mm/dd/yyyy)Date of Residence
From (mm/dd/yyyy)
Physical Address 44.
To (mm/dd/yyyy)
Date of Residence
Physical Address 22.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Date of Residence
1. Physical Address 1
From (mm/dd/yyyy) To (mm/dd/yyyy)
Date of Residence
Provide the following information about where you have lived during the last seven years.
List your most recent residence first and then every other residence where you have lived during the last seven years. There should be
no gaps in time. If you need extra space to complete this section, use the space provided in Part 12. Additional Information.
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/23/16 N Page 7 of 17
List where you have worked full-time or part-time during the last seven years. If you need extra space to complete this section, use
the space provided in Part 12. Additional Information.
Provide the following information about your employment.
1.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Your Occupation
Employer 1
Name of Employer
Part 5. Information About Your Employment
Date
Physical Address 5
From (mm/dd/yyyy)
5.
To (mm/dd/yyyy)
Date of Residence
Part 4. Information About Your Residence (continued)
2.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Your Occupation
Employer 2
Date
Name of Employer
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/23/16 N Page 8 of 17
Part 6. Information About Your Family
Provide the following information about your family (for example, spouse, children, and parents). If you need extra space to complete
this section, use the space provided in Part 12. Additional Information.
Spouse's Date of Birth (mm/dd/yyyy)
Family Name (Last Name) Given Name (First Name) Middle Name
Spouse's Current Legal Name
Information About Your SpouseA.
Spouse's Country of Birth
Spouse's Country of Citizenship or Nationality
Spouse's Physical Address
Employer 33.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Your Occupation
Date
Part 5. Information About Your Employment (continued)
Name of Employer
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Apt. Flr. NumberSte.
CountryProvince
Street Number and Name
Form I-191 12/23/16 N Page 9 of 17
Part 6. Information About Your Family (continued)
Child 2
Middle NameGiven Name (First Name)Family Name (Last Name)
Current Legal Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
B.
Middle NameGiven Name (First Name)Family Name (Last Name)
Child 1
Current Legal Name
Provide the following information about all of your children.
Information About Your Children
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/23/16 N Page 10 of 17
Part 6. Information About Your Family (continued)
Child 4
Middle NameGiven Name (First Name)Family Name (Last Name)
Current Legal Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
Child 3
Middle NameGiven Name (First Name)Family Name (Last Name)
Current Legal Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/23/16 N Page 11 of 17
Part 6. Information About Your Family (continued)
Parent 2's Date of Birth (mm/dd/yyyy)
Family Name (Last Name) Given Name (First Name) Middle Name
Parent 2's Current Legal Name
Parent 2's Country of Birth
Parent 2's Country of Citizenship or Nationality
Parent 2's Physical Address
Sex FemaleMale
Parent 1's Date of Birth (mm/dd/yyyy)
Family Name (Last Name) Given Name (First Name) Middle Name
Parent 1's Current Legal Name
Information About Your Parents
Parent 1's Country of Birth
Parent 1's Country of Citizenship or Nationality
Parent 1's Physical Address
Parent 1
C.
Sex FemaleMale
Parent 2
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
