Form I-602 Application by Refugee for Waiver of Grounds of Excludab

OMB No. 1615-0069; Expires 07/31/05

I-602, Application by Refugee for
Waiver of Grounds of Inadmissibility

Department of Homeland Security
U.S. Citizenship and Immigration Services

NOTE: To be completed by all applicants. Type or print in black ink.

Part 1. Information about applicant.
Family Name (in capital letters)

First Name

Present Address: Number and Street

City or Town

Date of Birth (mm/dd/yyyy)

Middle Name

State

A File Number
Zip Code

Place of Birth (City or Town)

Country of Birth

Country of Citizenship/Nationality

Part 2. Grounds of inadmissibility; reasons for requesting waiver.
I have been declared inadmissible or ineligible for adjustment of status under the following section(s) of 212(a) of the Immigration and Nationality
Act (INA): (NOTE: Sections 212(a)(4), 212(a)(5) and 212(a)(7)(A) do not apply to refugees under Sections 207 or 209 of the INA.)

I am inadmissible because: (List the specific acts, convictions or physical or mental conditions. If you have active or suspected tuberculosis, fully
complete Part 3 on Page 2. If you have, or have had, a physical or mental disorder and behavior associated with the disorder that may pose, or has
posed, a threat to the property, safety or welfare of you or others, fully complete Part 3A on Page 2.)

I request a waiver of the grounds inadmissibilty listed above for the following reasons (Check the appropriate block and explain below):

For humanitarian reasons

To assure family unity

Applicant 's Signature:

In the public interest

Date:

Do not write below this line. For USCIS use only.
Waiver of grounds of inadmissibilty is granted.

Basis for Favorable Action:

Waiver of grounds of inadmissibilty is denied. Basis for Denial:

Date of Action

USCIS District Director

USCIS District Office
Form I-602 (Rev. 03/31/06)Y

Part 3. Statements by applicant; physician and/or health facility;
endorsement by local or state health officer.
NOTE: To be completed for applicants with active or suspected tuberculosis or who have or have had a physical or mental
disorder and behavior associated with the disorder.

Section A. Statement by applicant.
Upon admission to the United States I will:
1. Go directly to the physician or health facility named in Part B below; and
2. Present copies of diagnostic tests Used in the medical examination to substantiate the diagnosis; and
3. Submit to counseling and such examinations, treatment and medical regimen as may be required: and
4. Remain under prescribed treatment or observation whether on inpatient or outpatient basis, until I am discharged.
Signature

Date

NOTE to Applicant's Sponsor in United States: Arrange for medical care of the applicant and have the physician complete
Section B below.

Section B. Statement by physician and/or health facility.
This section of Form I-602 may be executed by a private physician, health department, other public or private health facility or
military hospital. NOTE: Upon arrival of the alien in the United States, Form CDC 75.18, Report on Alien With Tuberculosis
Waiver, will be sent to the address given below.
I agree to supply any treatement or observation necessary for the proper management of the alien's tuberculosis
condition.
I agree to submit Form CDC 75.18 to the health officer named on Page 3 in Section C either (a) within 30 days
of the alien's reporting for care, indicating presumtive diagnosis, test results and plans for future care of the
alien; or (b) 30 days after recieving Form CDC 75.18, if the alien has not reported. (NOTE: Military Hospitals
should submit this form directly to the Centers for Disease Control, Atlanta, GA 30333.)
Satisfactory financial arrangements have been made. (NOTE: This statement does not relieve the alien of
submitting such evidence as the consul may require to establish that the alien is not likely to become a public
charge.)
I represent (Check the appropriate box and give the complete name and address of the facility):
1.

Local Health Department Outpatient Clinic

2.

Military Hospital

3.

Other Public or Private Health Facility

4.

Private Practice

Signature of Physician

Date:

Address: (If military, enter name and address of receiving hospital.)

NOTE to Applicant's Sponsor in United States: If medical care will be provided by a physician who checked Box 3 or 4 in Section B
above, have Section C on Page 3 completed by the local or state health officer who has jurisdiction in the area where the applicant plans
to reside in the United States. Provide the health officer with the address where the applicant plans to reside in the United States.
Form I-602 (Rev. 03/31/06) Y Page 2

C. Endorsement by local or state health officer.
Endorsement signifies recognition of the physiscian or facility for the purpose of providing care for tuberculosis. If the facility or
physician who signed in Section B on Page 2 is not in your health jurisdiction and not familiar to you, you may wish to contact the
health officer responsible for the jurisdiction of the facility or physician prior to endorsing.

Signature:

Date:

Enter name and address of the local health department to which Form CDC 75.18, Notice of Arrival of Alien With Tuberculosis
Waiver, should be sent when the alien arrives in the United States.
Local Health Department Address:

Paperwork Reduction Act Notice.
Under the Paperwork Reduction Act Notice, an agency may not conduct or sponsor an information colllection and a person is not
required to respond to a collection of information unless it contains a currently valid OMB control number. We try to create forms
that are accurate, can be easily understood and that impose the least possible burden on you to provide us with information. Often this
is difficult because some immigration laws are very complex. The estimated average time to complete and file this application is 15
minutes per application. If you have comments regarding the accuracy of this estimate or suggestions for maiking this form simpler,
write to U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W.,
Washington, DC 20529; OMB No. 1615-0069. Do not mail your completed application to this Washington, D.C. address.

Form I-602 (Rev. 03/31/06) Y Page 3