Form I-601A Application for Provisional Unlawful Presence Waiver

Application for Provisional Unlawful Presence Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services

For
USCIS
Use
Only

Initial Receipt

Fee Stamp

Resubmitted

Relocated
Received

USCIS
Form I-601A
OMB No. 1615-0123
Expires 03/31/2015

Action Block

Sent

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To be completed by an
attorney or
BIA-accredited
representative (if any).

Select this box if Form
G-28 is attached to
represent the applicant.

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

Your U.S. Mailing Address

Provide the following information about yourself.

7.a. In Care Of Name

1.

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

2.

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

3.

USCIS ELIS Account Number (if any)
►

Your Full Name

7.b. Street Number
and Name
7.c.

Other Names Used (if any)
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

Ste.

Flr.

7.d. City or Town

7.e. State
8.

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

4.c. Middle Name

Apt.

7.f.

ZIP Code

Is your current physical address the same as your mailing
address?
Yes
No
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

5.c. Middle Name

Other Information
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

10.

Date of Birth (mm/dd/yyyy)

11.

Gender

Male

Female

6.c. Middle Name
Form I-601A 03/04/13 N

Page 1 of 9

Part 1. Information About You (continued)

24.a. From (mm/dd/yyyy)

12.

City or Town of Birth

24.b. To (mm/dd/yyyy)

13.

Country of Birth

14.

Country of Citizenship or Nationality

25.

Immigration Status (at the time of entry)

26.

Are there other previous entries?

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

Your Immigration or Criminal History

27.

16.a. Father's Family Name (Last Name)

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

Date of Entry (mm/dd/yyyy)

18.a. Place or Port-of-Entry (City or Town)

If you answered "Yes" to Item Number 27., select the
statement below that most accurately describes your
current situation.

18.b. State

Immigration Status (at the time of entry)

28.a.

Your Previous Entries Into the United States
You were previously in the United States as follows:
20.a. Place or Port-of-Entry (City or Town)

21.a. From (mm/dd/yyyy)

22.

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.

Immigration Status (at the time of entry)

23.a. Place or Port-of-Entry (City or Town)

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.
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.

20.b. State

21.b. To (mm/dd/yyyy)

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.
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.
Yes
No

Your Last Entry Into the United States

19.

No

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.

15.a. Mother's Family Name (Last Name)

17.

Yes

23.b. State

Form I-601A 03/04/13 N

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Part 1. Information About You (continued)
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 the space provided 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.

30.

31.

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 the space provided
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?

Yes

No

36.b. Killing any person?

Yes

No

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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?
Yes
No
Have you EVER knowingly assisted or attempted to
assist the entry of someone, even a family member, into
the United States without the benefit of a valid travel
document in violation of U.S. law?
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

Yes

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
No

33.

Have you EVER trafficked in or are you NOW trafficking
in any controlled substance?
Yes
No

34.

Are you NOW or have you EVER knowingly assisted,
abetted, conspired, or colluded with others in the unlawful
trafficking of any controlled substance?
Yes
No

35.

Are you NOW or have you EVER been engaged in
prostitution?
Yes

No

No

36.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes

No

36.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No

Have you EVER:

37.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
Yes
No

37.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No

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?
Yes

No

32.

Form I-601A 03/04/13 N

36.c. Intentionally and severely injuring any person?

No

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?
Yes
No

40.

Have you EVER received any type of military,
paramilitary, or weapons training?
Yes

No

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?
Yes
No

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?
Yes
No
Page 3 of 9

Part 2. Biographic Information

Immigrant Visa Processing

1.

4.a. DOS Consular Case Number (NVC Case Number)

2.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

►
4.b. DOS DV Case Number (KCC Case Number)
►

Race (Select all applicable boxes)
White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

3.
4.
5.

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Height

Feet

Weight

Inches

Eye Color (Select only one box)
Blue
Green
Pink

Brown
Hazel

Unknown/Other

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

Black
Gray
White

Blond
Red

Provide the following information about the approved
immigrant visa petition (Form I-130, Form I-140, or Form
I-360) that is your basis to immigrate and the related
Department of State (DOS) immigrant visa application. If
you are a Diversity Visa (DV) Program selectee or a DV
Program derivative, provide information about your (or your
spouse's or parent's) DV case.

Approved Immigrant Visa Petition
USCIS Receipt Number
►

Petitioner's Full Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
3.

Company or Organization Name

Form I-601A 03/04/13 N

5.b. If you are an immigrant other than an immediate relative
of a U.S. citizen, did DOS initially act before [Date TBD]
to schedule you to appear at a U.S. Embassy or U.S.
Consulate for an immigrant visa interview based on the
approved immigrant visa petition in Part 3., Item
Number 1. or based on the DOS DV Case Number listed
in Part 3., Item Number 4.b.?
Yes
No

Unknown/
Other

Part 3. Information About Your Immigrant Visa
Petition and Your Immigrant Visa Case

1.

NOTE: USCIS may reject or deny your application if
you answer "Yes," do not answer this question, or answer
"No" but DOS records indicate that DOS initially acted
before January 3, 2013 to schedule you for an immigrant
visa interview.

Pounds

Black
Gray
Maroon

6.

5.a. If you are an immediate relative of a U.S. citizen, did DOS
initially act before January 3, 2013 to schedule you to
appear at a U.S. Embassy or U.S. Consulate for an
immigrant visa interview based on the approved immediate
relative immigrant visa petition listed in Part 3., Item
Number 1.?
Yes
No

NOTE: USCIS may reject or deny your application if
DOS initially acted before [Date TBD] to schedule you
for an immigrant visa interview.

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.

Your Qualifying Relative's Full Name and
Relationship to You
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.a.

U.S. Citizen Spouse

2.b.

U.S. Citizen Parent

2.c.

LPR Spouse

2.d.

LPR Parent

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Part 4. Information About Your Qualifying
Relative (continued)
Your Other Qualifying Relative
3.

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
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 the What Evidence Should I Submit With Form
I-601A section of the Instructions.

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Additional Qualifying Relative's Full Name and
Relationship to You
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

4.c. Middle Name
5.a.
5.b.
5.c.
5.d.

U.S. Citizen Spouse
U.S. Citizen Parent
LPR Spouse
LPR Parent

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.

Form I-601A 03/04/13 N

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Acknowledgement of Appointment at USCIS
Application Support Center

Part 6. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature

I,
,
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.

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

1.b.

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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.
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

,

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

,

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.

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 of U.S. immigration laws.
I certify, under penalty of perjury, that the information in my
application, my responses to each question, and any document
submitted with my application were provided by me and are
complete, true, and correct.

Applicant's Daytime Telephone Number

Applicant's Signature
4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

6.a. Applicant's Signature

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

Form I-601A 03/04/13 N

Page 6 of 9

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

Part 7. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.

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

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

Interpreter's Signature

2.

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Interpreter's Business or Organization Name (if any)

6.a. Interpreter's Signature

Interpreter's Mailing Address

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

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Part 8. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant

Flr.

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

3.e. ZIP Code

Provide the following information about the preparer.

Province

Preparer's Full Name

3.g. Postal Code

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

3.h. Country

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

Interpreter's Contact Information
4.

5.

2.

Preparer's Business or Organization Name (if any)

Interpreter's Daytime Telephone Number

Preparer's Mailing Address

Interpreter's Email Address (if any)

3.a. Street Number
and Name

Interpreter's Certification

3.b.

I certify that:

3.c. City or Town

I am fluent in English and
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.

Form I-601A 03/04/13 N

Apt.

3.d. State
3.f.

Ste.

Flr.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

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Part 8. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant (continued)
Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

6.

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Preparer's Email Address (if any)

Preparer's Statement
7.a.

7.b.

I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.

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 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

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

Form I-601A 03/04/13 N

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5.a. Page Number

Part 9. 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; type or print the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.

5.b. Part Number

5.c. Item Number

5.d.

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

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1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-601A 03/04/13 N

4.c. Item Number

7.a. Page Number

7.d.

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