Form I-690 Application for Waiver of Grounds of Excludability

OMB No. 1615-0032; Expires 12/31/06

I-690, Application for Waiver
of Grounds of Inadmissibility

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

Instructions
1. What Is the Purpose of This Form?
This form is used to apply for a waiver of inadmissibility by
an applicant for adjustment of status under section 245A or
210 of the Immigration and Nationality Act (INA).
A separate waiver application must be filed by each
applicant who is inadmissible. All applications must be
typed or clearly printed in black ink and completed in full. If
extra space is needed to answer an item, attach a
continuation sheet and indicate your name, "A" file number
and item number.

You can apply for a waiver of the vaccination
requirements without filing this form and without
paying a fee, if:

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2. Special Instructions for Individuals Applying for a
Waiver of One or More of the Medical Grounds
Under Section 212(a)(1)(A) of the INA.
A. Applicants who Require a Waiver for Human
Immunodeficiency Virus (HIV) or Tuberculosis (TB).
The physician or medical facility that will provide the
required treatment to you must fill out Part C of the
accompanying TB/HIVsupplement. If that physician or
health care facility is not part of the state or local health
department, then the local health department in the
jurisdiction where you will reside must also complete and
sign Part D. If you are outside of the United States, a
relative in the United States must complete this process
for you.
After the TB/HIV supplement has been completed, attach
the supporting documents and file your waiver
application. If you are inadmissible because of HIV and/
or TB and your waiver application does not include a
properly completed HIV/TB supplement, your waiver
application will be returned to you.
B. Applicants Requesting a Waiver of the Vaccination
Requirements of INA 212(a)(1)(A)(ii)
If your waiver application is based on religious or moral
objections to vaccinations, you must establish that:

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.
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You object to vaccinations in any form; and
You object because of your religious beliefs or
moral convictions (you do not need to be a member
of a "mainstream" or recognized religion); and
Your beliefs are sincere.

At a minimum, you must submit a personal statement
describing the basis of your objection.

You initially did not submit proof that you have
received the required vaccines, but you are
vaccinated now; or
It is not medically appropriate for you to have one
or more of the missing vaccines. The physician
will make this certification according to the
applicable regulations published by the Department
of Health and Human Services (HHS) and the
accompanying technical instructions for physicians
designated to perform the required medical
examination. These instructions are published by
the Centers for Disease Control and Prevention
(CDC). According to these technical instructions,
"not medically appropriate" covers the following
situations:
The vaccination is not recommended by the
Advisory Committee for Immunization
Practices (ACIP) for your age group; or
The vaccination is medically contraindicated;
or
There is an insufficient interval between doses
for vaccines requiring a series of doses; or
It is not the flu season (for the flu vaccine
only).

C. Applicants Who Have a Physical or Mental Disorder
With Associated Harmful Behavior - INA 212(a)(1)(A)
(iii)(I) or (II).
If the examining physician determines that you have a
physical or mental disorder with associated harmful
behavior, or a past history of a physical or mental
disorder with harmful behavior that is likely to recur, the
medical examination report completed by the designated
physician will, at a minimum, contain the following
information, as required by HHS regulations at 42 CFR
part 34 and the accompanying technical instructions
published by the CDC:

.

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A complete medical history, including the details of
any prior or current hospitalization, treatment, or
care;
The current findings, diagnosis, and prognosis; and
Any other information necessary for USCIS to
determine, in consultation with HHS, the terms and
conditions that should be imposed on the waiver, if
it is granted.
Form I-690 Instructions (Rev. 10/26/05)Y

D. Applicants Who Are Inadmissible because of
Substance or Drug Abuse or Substance or Drug
Addiction - INA 212(a)(1)(A)(iv)
The designated physician will determine whether you are
currently using, or have used in the past, any controlled or
psychoactive substance. The examining physician will
make this determination during the required medical
exam, according to the applicable HHS regulations at 42
CFR part 34 and the accompanying technical instructions
published by the CDC.
If you are inadmissible under INA 212(a)(1)(A)(iv) due to
drug abuse or drug addiction, you may apply for a waiver.
USCIS will exercise discretion in determining whether to
grant this waiver, after consulting with HHS, and if you
are not inadmissible on any other grounds that cannot be
waived.
You are not inadmissible under INA 212(a)(1)(A)(iv) if
the designated physician that performed the required
medical exam determined that you are in remission for
prior drug use or abuse or that your prior drug use was
strictly experimental. The designated physician will
determine whether any prior drug use is in remission, or
whether it was strictly experimental, based on the
applicable HHS regulations and the accompanying
technical instructions published by the CDC.
Note the following key items:

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If you engaged in the use of any controlled
substance, and such use was illegal at the place
where it occurred, your admission to the examining
physician may be sufficient to make you
inadmissible on criminal grounds under INA 212(a)
(2)(A)(i)(II) relating to any controlled substance
violation (U.S. or foreign).
The USCIS officer reviewing your primary benefit
application (Form I-687, Form I-698, Form I-700,
and/or Form I-485) will determine whether this
admission to the designated physician makes you
inadmissible under INA 212(a)(2)(A)(i)(II).
The only drug offense under INA 212(a)(2)(A)(i)(II)
that can be waived is one offense of simple
possession of marijuana (30 grams or less).
Any willful concealment or misrepresentation of any
material fact made to procure an immigration benefit
(including any willful concealments or
misrepresentations made to avoid being found
inadmissible under any provision), will result in the
denial of this waiver application and your primary
benefit application. You may also become subject to
additional penalties under the law.

3. What Is the Fee?
You must pay $95.00 to file this application. The fee is
not refundable, whether the application is approved or
denied.
Do not mail cash. A separate check or money order
must be submitted for each application. All checks or
money orders, whether U.S. or foreign, must be payable
in U.S. currency at a financial institution in the United
States. When a check is drawn on the account of a
person other than yourself, write your name on the face
of the check. If the check is not honored, USCIS will
charge you $30.00.The check or money order must be in
the exact amount payable to the U.S. Department of
Homeland Security, unless:

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If you live in Guam, make the check or money
order payable to the "Treasurer, Guam" or
If you live in the U.S. Virgin Islands, make your
check or money order payable to the
"Commissioner of Finance of the Virgin Islands."

How to Check if the Fee is Correct?
The fee on this form is current as of the edition date
appearing in the lower right corner of this page. However,
because USCIS fees change periodically, you can verify if
the fee is correct by following one of the steps below:

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.
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Visit our website at www.uscis.gov and scroll down
to "Forms and E-Filing" to check the appropriate
fee, or
Review the Fee Schedule included in your form
package, if you called us to request the form, or
Telephone our National Customer Service Center at
1-800-375-5283 and ask for the fee information.

4. Where Must the Application Be Filed?
You must file this waiver application with the USCIS office
that has jurisdiction over your primary benefit application -Form I-687, Form I-698 and/or Form I-485.

5. Do You Need Forms or Information?
To order USCIS forms, call our toll-free forms line at
1-800-870-3676. You can also order USCIS forms and obtain
information on immigration laws, regulations and procedures
by telephoning our National Customer Service Center tollfree at 1-800-375-5283 or visiting our internet website at
www.uscis.gov.

Form I-690 Instructions (Rev. 10/26/05)Y Page 2

6. Use InfoPass for Appointments.
As an alternative to waiting in line for assistance at your
local USCIS office, you can now schedule an appointment
through our internet-based system, InfoPass. To access
the system, visit our website at www.uscis.gov. Use the
InfoPass appointment scheduler and follow the screen
prompts to set up your appointment. InfoPass generates
an electronic appointment notice that appears on the
screen. Print the notice and take it with you to your
appointment. The notice gives the time and date of your
appointment, along with the address of the USCIS office.

7. Paperwork Reduction Act Information.
An agency may not conduct or sponsor an information
collection and a person is not required to respond to this
collection of information unless it displays a currently
valid OMB control number.
The estimated average time to complete and file this
application is 15 minutes per application.
If you have comments regarding this form you can write to
U.S. Citizenship and Immigration Services, Regulatory
Management Division, 111 Massachusetts Avenue, N.W.,
Washington, DC 20529; OMB No. 1615-0032. Do not
mail your completed application to this address.

Form I-690 Instructions (Rev. 10/26/05)Y Page 3

OMB No. 1615-0032; Expires 12/31/06

I-690, Application for Waiver
of Grounds of Inadmissibility

Department of Homeland Security
U.S. Citizenship and Immigration Services
For Government Use Only.
Fee Stamp

Fee Receipt Number (This application):

Alien Registration Number (A# of This Applicant):

APPLICANT: See instructions before filling in this application. If you need more space to answer fully any question on this form,
use a separate sheet and identify each answer with the number of the corresponding question. Type or print in black ink.
1. Family Name (Last Name in CAPITAL letters)

3. Address (No. and Street)

(First Name)

(Middle Name)

(Apt. No.)

(City/Town)

4. Place of Birth (City or Town and County, Province or State)

6. Date of Visa Application (mm/dd/yyyy) for:

(Country)

Permanent Residence

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

(State/Country)

(Zip/Postal Code)

5. U.S. Social Security Number

7. Visa applied for at:

Temporary Residence
8. I am applying for a waiver of:
212 (a)(6)(A)(i)

212 (a) (1)(A)(i), (ii), (iii) or (iv)

212(a)(6)(C)(i) or (ii)

212(a)(9)(B)(i)(I) or (i)(II)

212 (a)(2)(C)(i)(II) - possession of marijuana, 30 gms or less

212(a)(6)(D) and/or (E)

212(a)(9)(C)(i)(I) or (i)(II)

212(a)(9)(A)(i) or (ii)

212(a)(8)(A) and/or (B)

212 (a)(10)(A), (B), (C), (D), and/or (E) - Please specify:

9. List reasons of inadmissibility:

10. List all immediate relatives in the United States (parents, spouse and children):
Name

Address

Relationship

Immigration Status

11. I should be granted a waiver because: (Describe family unity considerations or humanitarian or public interest reasons for granting a waiver). If more space is
needed attach an additional sheet.
12. Applicant's Signature

13. Date

FOR USCIS USE ONLY. Recommended by:
(Print Name and Title)
Signature

Date
Stamp #

Director
Form I-690 (10/26/05)Y

Supplement for Applicants With Human Immunodeficiency Virus (HIV) Infection or Tubercoulosis (TB)
Part A. Applicant's Sponsor in the U.S.

b. If at the end of the 30-day period the applicant fails to
appear for evaluation and/or care as required, I will submit
a report to that effect to the CDC.

1. Make arrangements for the applicant's medical care and have
the attending physician or facility complete Part C.
2. Obtain the necessary endorsements.
a. Treatment is being provided by a state or local health
department: If a state or local health department will
provide the necessary care and/or treatment to the
applicant, that facility should check block (a) in Number
4 under Part C. The health department is not required to
complete anything else on this form.
b. Treatment is being provided by a private physician or
by any other private or public facility: If a private
physician, a private medical facility or a public medical
facility (other than a state or local health department) will
provide the applicant's medical care and/or treatment, that
facility should check block (b) or (c) under Number 4 of
Part C, as applicable. In that case, the state or local
health department in the jurisdiction where the applicant
will reside must complete Part D.
3. Address in the United States where the applicant plans to reside:
Address (Number and Street)

(Apartment No.)

3. Satisfactory financial arrangements have been made for the
applicant's medical care and treatment. (This statement does
not relieve the applicant from submitting evidence, as
required by the consular officer or USCIS, to establish that
he or she is not likely to become a public charge (another
ground of inadmissibility under section 212(a)(4) of the
Immigration and Nationality Act).
4. I represent: (Check the appropriate box and provide the
information requested below)

5.

a.

Local Health Department

b.

Other Public Health Facility

c.

Private Medical Practice

I agree to submit a copy of my evaluation to the health
officer indicated in Part D. (Required if you checked block
(b) or (c) in Number 4 directly above.)

Name of Physician or Facility (Please type or print)
Address (Number and Street)

City, State and Zip Code

City, State and Zip Code

Part B. Applicant's Statement:

Signature of Physician

Date

Upon admission to the United States I will:

1. Go directly to the physician or health facility named in
Number 5 of Part C;
2. Present copies of diagnostic tests used on the visa
examination to substantiate diagnosis;
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 discharged.

Part D. Endorsement of Local or State Health Officer :
Endorsement signifies recognition of the physician or facility for
the purpose of providing care for HIV infection or tuberculosis.
If the facility physician who signed in Part C is not in your
health jurisdiction or is not familiar to you, you may wish to
contact the health officer responsible for the jurisdiction, and/or
the physician, before you sign this endorsement.
Official Name of Department (Please type or print)

Part C. Statement by Physician or Health Facility:
1. I agree to supply counseling and any treatment or
observation necessary for the proper management of the
applicant's condition. (Check applicable box(es):
HIV Infection

Tuberculosis

2. I agree to submit a copy of my evaluation to the Division of
Global Migration and Quarantine (E03), Centers for Disease
Control and Prevention, Atlanta, Georgia 30333, and certify
the following:
a. I will submit a copy of my evaluation within 30 days
of the date the applicant is required to appear for
evaluation and/or care; and

Signature

Date

Name of Health Department to receive the required notice from the CDC
following the Applicant's arrival in the U.S./adjustment of status. (Please

type or print)

Address (Number and Street)
City, State and Zip Code

Form I-690 (10/26/05)Y Page 2