Fillable Printable I 601A

I 601A

Page 1 of 9Form I-601A 12/23/16 N

Application for Provisional Unlawful Presence Waiver

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-601A

OMB No. 1615-0123

Expires 07/31/2018

Fee Stamp

For

USCIS

Use

Only

Relocated

Action Block

SentReceived

Initial Receipt

Resubmitted

START HERE - Type or print in black ink.

►

Select this box if

Form G-28 is

attached to represent

the applicant.

Attorney State Bar Number

(if applicable)

Attorney or Accredited Representative

USCIS Online Account Number (if any)

To be completed by an

attorney or

BIA-accredited

representative (if any).

►

Part 1. Information About You

Alien Registration Number (A-Number) (if any)1.

U.S. Social Security Number (if any)

►

A-

Provide the following information about yourself.

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3.USCIS Online 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

Your U.S. Mailing Address

Street Number

and Name

7.a.

In Care Of Name

7.b.

7.c.Apt.Ste.Flr.

7.d. City or Town

7.e. State7.f.ZIP Code

10.

9.d.State9.e.ZIP Code

9.c.City or Town

Street Number

and Name

9.a.

9.b.Flr.Ste.Apt.

If you answered "No" to Item Number 8., provide your

physical address in Item Numbers 9.a. - 9.e.

8.Is your current physical address the same as your mailing

address?

Gender

MaleFemale

YesNo

Other Information

Your U.S. Physical Address

11.Date of Birth (mm/dd/yyyy)

Page 2 of 9Form I-601A 12/23/16 N

Part 1. Information About You (continued)

12.City or Town of Birth

13.Country of Birth

14.Country of Citizenship or Nationality

Immigration Status (At the time of entry)19.

Place or Port-of-Entry (Actual or approximate city or town)

State

Date of Entry (On or about mm/dd/yyyy) 17.

Your Last Entry Into the United States

18.a.

18.b.

15.a.

Father's Family Name (Last Name)

16.b.Father's Given Name (First Name)

16.a.

Mother's Given Name (First Name) 15.b.

Mother's Family Name (Last Name)

Your Previous Entries Into the United States

To (On or about mm/dd/yyyy) 21.b.

You were previously in the United States as follows:

From (On or about mm/dd/yyyy)21.a.

Place or Port-of-Entry (Actual or approximate city or town)

State

20.a.

20.b.

Immigration Status (At the time of entry)22.

To (On or about mm/dd/yyyy) 24.b.

From (On or about mm/dd/yyyy)24.a.

Immigration Status (At the time of entry)25.

Are there other previous entries?26.

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 the space

provided in Part 9. Additional Information.

YesNo

Your Immigration or Criminal History

State23.b.

23.a.Place or Port-of-Entry (Actual or approximate city or town)

Are you currently in removal, exclusion, or deportation

proceedings in which there is no final order issued by the

immigration judge, the Board of Immigration Appeals, a

DHS officer, or a Federal court yet? (This includes

proceedings under INA section 239, an exclusion or

deportation proceeding initiated before April 1,1997, a

Visa Waiver Program removal proceeding under INA

section 217, expedited removal under INA 235, and a

request for a judicial removal order under INA section

238(c))?

27.

YesNo

If you answered “No” to Item Number 27., go to Item

Number 29.a. If you answered “Yes” to Item Number

27., select the statement below (either Item Number

28.a. or 28.b.) that most accurately describes your current

situation.

NOTE: You may be eligible for a provisional

unlawful presence waiver. 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.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 EOIR's calendar to continue my

removal, exclusion, or deportation proceedings.

Page 3 of 9Form I-601A 12/23/16 N

28.b.

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.

Part 1. Information About You (continued)

NOTE: You are ineligible for a provisional

unlawful presence waiver unless your proceedings

are administratively closed at the time you file your

Form I-601A, and the proceedings have not been

put back on EOIR's calendar to continue your

removal, exclusion, or deportation after having been

previously administratively closed.

29.a.

29.b.

Are you currently subject to a final order of removal,

exclusion or deportation? (This includes an order entered

in proceedings under INA section 239, an exclusion or

deportation order entered in proceedings initiated before

April 1, 1997, a Visa Waiver Program removal order

under INA section 217, an expedited removal order

under

INA section 235, and a judicial order under INA section

238(c))?

Yes No

NOTE: If you answered "Yes" to Item Number 29.a.,

you are ineligible for a provisional unlawful presence

waiver unless you applied for, and USCIS has already

approved, an application for permission to reapply for

admission under INA section 212(a)(9)(A)(iii) and 8 CFR

212.2 on Form I-212, Application for Permission to

Reapply for Admission into the United States after

Deportation or Removal. If you have already applied for

and if USCIS has already granted you permission to

reapply for admission, provide the relevant information in

Item Number 29.b. If you answered "No" to Item

Number 29.a., go to Item Number 31.

USCIS Receipt Number for Your Approved Form I-212:

►

NOTE: You may also provide a copy of the approval

notice that USCIS sent to you when it approved your

Form I-212.

If you were granted voluntary departure in the past, but

then you withdrew your voluntary departure request or

otherwise terminated voluntary departure you should not

select "Yes" to Item Number 31. In this case you may be

in removal proceedings or you may be the subject of a

final order of removal, deportation, or exclusion. You

should select the statements that apply to you in Item

Numbers 27. - 28.b. or Item Number 29.a. If you filed

a motion to withdraw your voluntary departure request,

please submit a copy with your Form I-601A.

Answer Item Numbers 32. - 38. If you answer "Yes" to any

question in Item Numbers 32. - 38., your application for a

provisional unlawful presence waiver may be denied as a matter

of discretion. For each "Yes" response for Item Numbers 32. -

38., provide the location and date of the event and a brief

description in Part 9. Additional Information. For Item

Number 32., if you were arrested but not charged with any

crime or offense, provide a statement or other documentation

from the arresting authority, prosecutor's office, or court to

show that you were not charged with any crime or offense. If

you answer "Yes" to Item Number 35., you must provide all

related court dispositions.

Have you EVER knowingly and willfully given false or

misleading information to a U.S. Government official

while applying for an immigration benefit or to gain entry

or admission into the United States?

32.

Have you EVER been engaged in alien smuggling?33.

Yes No

Have you EVER been arrested, cited, or detained by a

law enforcement officer (including immigration and

military officers) in the United States, your home country,

and/or any other country for any reason other than traffic

violations?

Yes No

34.

Have you EVER trafficked in or are you NOW trafficking

in any controlled substance?

Have you EVER been charged, indicted, convicted,

imprisoned, or jailed in the United States, your home

country, and/or any other country for any crime or

offense?

Yes

35.

36.

30.a.Has DHS served you with a DHS Form I-871, giving you

notice that DHS intends to reinstate a prior deportation,

exclusion, or removal order against you as permitted

under INA section 241(a)(5)?

Yes

NoYes

If you answered "Yes" to Item Number 30.a., has DHS

served you with a final decision reinstating a prior

deportation, exclusion, or removal order under INA

section 241(a)(5)?

31.Are you currently subject to a grant of voluntary

departure that has not expired and that was granted to you

by the immigration judge or the Board of Immigration

Appeals during removal, exclusion, or deportation

proceedings?

Yes No

NOTE: If you answered "Yes" to Item Number 31., you

are ineligible for a provisional unlawful presence waiver.

30.b.

Page 4 of 9Form I-601A 12/23/16 N

Part 1. Information About You (continued)

Are you NOWor have you EVER been engaged in

prostitution?

Yes

38.

37.Are you NOW or have you EVER knowingly assisted,

abetted, conspired, or colluded with others in the unlawful

trafficking of any controlled substance?

AnswerItem Numbers 39.a. - 45.If you answer "Yes" to any

question in Item Numbers 39.a. - 45., your application for a

provisional unlawful presence waiver may be denied as a

matter of discretion. For each "Yes" response for Item

Numbers 39.a. - 45., provide a complete explanation in

Part 9. Additional Information.

YesNoActs involving torture or genocide? 39.a.

Haveyou EVER ordered,incited, called for, committed,assisted,

helped with,orotherwise participated inanyofthefollowing:

39.b.Killing any person?

NoYes

Limiting or denying any person's ability to exercise

religious beliefs?

Yes

39.d.

YesNo

39.e.

Engaging in any kind of sexual contact or relations with

any person who was being forced or threatened?

NoYes

Intentionally and severely injuring any person?39.c.

40.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?

NoYes

Have you EVER:

Served in any prison, jail, prison camp, detention facility,

labor camp, or any other situation that involved detaining

persons?

YesNo

40.b.

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?

YesNo

41.

Have you EVER received any type of military,

paramilitary, or weapons training?

44.

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?

YesNo

45.

NoYes

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?

YesNo

43.

Part 2. Biographic Information

Not Hispanic or Latino

Hispanic or Latino

Ethnicity (Select onlyone box)

Hair Color (Select only one box) 6.

Height

4.Weight

FeetInches

Pounds

Race (Select allapplicable boxes)

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

White

Asian

Black or African American

Black

Brown

Green

MaroonPink

HazelGray

Blue

5.Eye Color (Select only one box)

Unknown/Other

Black

BrownRed

White

Unknown/

Other

Sandy

Gray

BlondBald (No hair)

42.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?

NoYes

Page 5 of 9Form I-601A 12/23/16 N

Part 3.Information About Your Immigrant

Visa Case

1.a.

1.b.

1.c.

1.d.

1.e.

2.a.

Provide the basis on which you are immigrating to the United

States using the check boxes below. (Selectonly onebox)

Diversity Visa Program Selectee or Derivative

Immediate Relative Petition (Form I-130)

Employment-Based Petition (Form I-140), including

Derivatives

Special Immigrant/Widow Petition (Form I-360),

including Derivatives

Preference-Based Family Petition (Form I-130),

including Derivatives

If you selected Item Number1.a. because you are a Diversity

Visa (DV) Program selectee or derivative, provide information

about your (or your spouse's or parent's) DV case:

DOS DV Case Number (KCC Case Number)

►

DV Program Selectee's Full Name (If you are a derivative and

your parent or spouse is the DV Program Selectee)

2.b.Family Name

(Last Name)

2.c. Given Name

(First Name)

2.d. Middle Name

3.a.

3.b.

If you selected Item Numbers1.b., 1.c., 1.d., or 1.e. provide

the following information about the approved immigrant visa

petition (Form I-130, Form I-140, or Form I-360) that was filed

on your (or your spouse's or parent's) behalf, or that you used to

self-petition on your behalf, that is your basis to immigrate and

the related Department of State (DOS) immigrant visa

application.

►

USCIS Receipt Number

►

DOS Consular Case Number (NVC Case Number)

Petitioner Name (Provide the full name of the family member or

the company who petitioned for you (or your spouse or parent).)

3.c.Family Name

(Last Name)

3.d.Given Name

(First Name)

3.e.Middle Name

Company or Organization Name3.f.

Part 4. Information About Your Qualifying

Relative

Provide the following information about the qualifying relative

(the U.S. citizen or Lawful Permanent Resident (LPR) spouse or

parent) who would experience extreme hardship if you were

refused admission to the United States.

1.a.Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c.Middle Name

2.a.

LPR Parent

LPR Spouse

2.d.

2.c.

2.b.

U.S. Citizen Spouse

U.S. Citizen Parent

Your Qualifying Relative's Full Name and

Relationship to You

Do you have more than one qualifying relative (U.S. citizen

or LPR spouse or parent)?

Yes No

If you answered "Yes" to Item Number 3., provide the

other qualifying relative's name and your relationship to

the qualifying relative in Item Numbers 4.a. - 5.d.

Also provide evidence of the U.S. citizenship or LPR

status of the other qualifying relative with your

application.See theWhat Evidence Must I Submit

With Form I-601A section of the Instructions.

Your Other Qualifying Relative

4.a.Family Name

(Last Name)

4.b. Given Name

(First Name)

4.c.Middle Name

Additional Qualifying Relative's Full Name and

Relationship to You

5.a.

5.b.

5.d.

5.c.

LPR Parent

LPR Spouse

U.S. Citizen Spouse

U.S. Citizen Parent

Page 6 of 9Form I-601A 12/23/16 N

Part 5. Statement From Applicant

In the space provided, explain in detail why you believe USCIS

should approve your application for a provisional unlawful

presence waiver as a matter of discretion. Provide all of the

reasons you believe support your application for this waiver,

including information about the extreme hardship your

qualifying relatives would experience if you were refused

admission to the United States. If you need extra space to

complete your statement, use the space provided in Part 9.

Additional Information.

Part 6. Applicant's Statement, Contact

Information, Certification, and Signature

I can read and understand English, and I have read

and understand every question and instruction on this

application and my answer to every question.

1.b.

The interpreter named in Part 7. read to me every

question and instruction on this application and my

answer to every question in

1.a.

a language in which I am fluent, and I understood all

of this information as interpreted.

NOTE: Read the Penalties section of the Form I-601A

Instructions before completing this part. You must file Form

I-601A while in the United States.

NOTE: Select the box for either Item Number 1.a. or 1.b. If

applicable, select the box for Item Number 2.

Applicant's Statement

2.At my request, the preparer named in Part 8.,

prepared this application for me based only upon

information I provided or authorized.

5.Applicant's Email Address (if any)

3.Applicant's Daytime Telephone Number

Applicant's Contact Information

Applicant's Mobile Telephone Number (if any)4.

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 of my records that USCIS may need to determine my

eligibility for the immigration benefit I seek.

I further 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.

Page 7 of 9Form I-601A 12/23/16 N

Part 7. Interpreter's Contact Information,

Certification, and Signature

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

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

Interpreter's Business or Organization Name (if any)2.

Interpreter's Full Name

Provide the following information about the interpreter.

Interpreter's Mailing Address

3.c.City or Town

Street Number

and Name

3.a.

3.b.Ste.Flr.Apt.

3.h.

3.d.State3.e.ZIP Code

3.f.Province

Country

3.g.Postal Code

Interpreter's Contact Information

Interpreter's Mobile Telephone Number (if any)5.

Interpreter's Daytime Telephone Number

Interpreter's Email Address (if any)6.

I certify, under penalty of perjury, that I provided or authorized

all of the information in my application, I understand all of the

information contained in, and submitted with, my application,

and that all of this information is complete, true, and correct.

1) I reviewed and provided or authorized all of the

information in my application;

2) I understood all of the information contained in, and

submitted with, my application; and

3) All of this information was complete, true, and correct

at the time of filing.

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

Applicant's Signature6.a.

Applicant's Signature

NOTE TO ALL APPLICANTS: If you do not completely fill

out this application or fail to submit required documents listed

in the Instructions, USCIS may deny your application.

Part 6. Applicant's Statement, Contact

Information, Certification, and Signature

(continued)

Interpreter's Certification

I certify, under penalty of perjury, that:

I am fluentinEnglish and ,

which is the same language specified in Part 6., Item Number

1.b., and I have read to this applicant in the identified language

every question and instruction on this application and his or her

answer to every question. The applicant informed me that he or

she understands every instruction, question, and answer on the

application, including the Applicant's Certification, and has

verified the accuracy of every answer.

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

Interpreter's Signature (sign in ink)7.a.

Interpreter's Signature

I understand that USCIS will require me to appear for an

appointment to take my biometrics (fingerprints, photograph,

and/or signature) and, at that time, I will be required to sign an

oath reaffirming that:

Page 8 of 9Form I-601A 12/23/16 N

Preparer's Statement

I am not an attorney or accredited representative but

have prepared this form on behalf of the authorized

individual and with the authorized individual's consent.

7.a.

7.b.I am an attorney or accredited representative and

have prepared this form on behalf of the authorized

individual and with the authorized individual's

consent.

NOTE: If you are an attorney or accredited

representative, you may be obliged to submit a

completed Form G-28, Notice of Entry of

Appearance as Attorney or Accredited

Representative, with this application.

By my signature, I certify, under penalty of perjury, that I

prepared this application at the request of the applicant. The

applicant then reviewed this completed application and informed

me that he or she understands all of the information contained

in, and submitted with, his or her application, including the

Applicant's Certification, and that all of this information is

complete, true, and correct. I completed this application based

only on information that the applicant provided to me or

authorized me to obtain or use.

Preparer's Certification

8.a. Preparer's Signature (sign in ink)

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

Preparer's Signature

Part 8.Contact Information, Declaration, and

Signature of the Person Preparing this

Application, if Other Than the Applicant

Preparer's Business or Organization Name (if any)2.

Preparer's Full Name

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

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

Provide the following information about the preparer.

Preparer's Mailing Address

3.c.City or Town

Street Number

and Name

3.a.

3.b.Ste.Flr.Apt.

3.h.

3.d.State3.e.ZIP Code

3.f.Province

Country

3.g.Postal Code

Preparer's Contact Information

4.Preparer's Daytime Telephone Number

5.Preparer's Mobile Telephone Number (if any)

6.Preparer's Email Address (if any)

Page 9 of 9Form I-601A 12/23/16 N

Part 9. Additional Information

3.d.

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. Type or print 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

3.a.3.b.3.c.Page NumberPart NumberItem Number

►

A-

A-Number (if any)2.

4.d.

4.a.4.b.4.c.Page NumberPart NumberItem Number

5.d.

5.a.5.b.5.c.Page NumberPart NumberItem Number

6.d.

6.a.6.b.6.c.Page NumberPart NumberItem Number

7.d.

7.a.7.b.7.c.Page NumberPart NumberItem Number