Form I-601 Application for Waiver of Grounds of Inadmissibility

OMB No. 1615-0029; Expires 01/31/07

I-601, Application for Waiver
of Grounds of Inadmissibility

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

Instructions
NOTE: Please read instructions carefully. Fee will not be refunded. Type or print legibly in black ink.
Unless the applicant resides in the U.S. Virgin Islands or
Guam, the check or money order must be made payable to
the Department of Homeland Security.

1. Filing the Application.
The application and supporting documents should be taken or
mailed to:

If the applicant resides in Guam, make the check or
money order payable to the "Treasurer, Guam."

The American Embassy or Consulate where the applicant
is applying for a visa, if the applicant is not in the United
States; or

If the applicant resides in the U.S. Virgin Islands,
make the check or money order payable to the
"Commissioner of Finance of the Virgin Islands."

The office of the U.S. Citizenship and Immigration
Services (USCIS) having jurisdiction over the applicant's
place of residence, if the applicant is in the United States
and applying for status as a permanent resident.

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:

2. What is the Fee?
No fee is required if this application is filed for an alien who:

Is mentally retarded; or

Visit our website at www.uscis.gov and scroll down
to "Forms and E-Filing" to check the appropriate fee,
or

Has a history of mental illness.

Review the Fee Schedule included in your form
package, if you called us to request the form, or

Is afflicted with tuberculosis;

All other applications must be accompanied by a fee of $265.00.
The fee cannot be refunded, regardless of the action taken on the
application. Do not mail cash.
NOTE: Only a single application and fee is required when an
alien is applying simultaneously for a waiver of both sections
212(h) and (i) of the Immigration and Nationality Act.

Telephone our National Customer Service Center at
1-800-375-5283 and ask for the fee information.

3.

Applicants With Tuberculosis.
An applicant with active tuberculosis or suspected
tuberculosis must complete Statement A on Page 3 of
this form. The applicant and his or her sponsor are also
responsible for having:

Payment must be made by a check or money order:
Drawn on a bank or other institution located in the United
States;
Payable in U.S. currency; and
Payable in the exact amount.

Statement B completed by the physician or health
facility which has agreed to provide treatment or
observation.
Statement D, if required, completed by the
appropriate local or state health officer.

If the check is drawn on an account of a person other than
the applicant, the name of the applicant must be entered on the
face of the check.

This form should then be returned to the applicant for
presentation to the consular office or appropriate USCIS
office.

Personal checks are accepted subject to collectibility. An
uncollectible check will void the application and any documents
issued pursuant to the application. A charge of $30.00 will be
imposed if the check is not honored by the bank on which it is
drawn.

Submission of the application without the required fully
executed statements will result in the return of the
application to the applicant without further action.

Form I-601 Instructions (Rev. 10/26/05)Y

4.

Applicants With HIV Infection.

The medical report will be referred to the U.S. Public
Health Service for review and, if found acceptable, the alien
will be required to submit such additional assurances as the
U.S. Public Health Service may deem necessary in his or
her particular case.

An applicant with Human Immunodeficiency Virus
(HIV) infection must complete Statement A on Page 4 of
this form. If the applicant has a sponsor, the sponsor
must complete Statement C. The applicant and his or her
sponsor are also responsible for having:
Statement B completed by physician or health
facility which has agreed to provide counseling
and treatment or observation, and

6.

To order USCIS forms, telephone our toll-free forms line at
1-800-870-3676. You can also get USCIS forms and
information on immigration laws, regulations and
procedures, by calling our National Customer Service
Center at 1-800-375-5283 or visiting our website at www.
uscis.gov.

Statement D, if required, completed by the
appropriate local or state health officer.
This form should then be returned to the applicant for
presentation to the consular officer or appropriate USCIS
office.
Submission of the application without the required fully
executed statements will result in the return of the
application to the applicant without further action.

5.

7.

An alien who is mentally retarded or who has a history of
mental illness shall attach a statement that arrangements
have been made for the submission of a medical report, as
follows, to the office where this form is filed:
The medical report shall contain:

Findings as to the current physical condition of the
alien, including reports of chest X-rays and a
serologic test if the alien is 15 years of age or older,
and other pertinent diagnostic tests; and
Findings as to the current mental condition of the
alien, with information as to prognosis and life
expectancy and with a report of a psychiatric
examination conducted by a psychiatrist who shall, in
the case of mental retardation, also provide an
evaluation of intelligence.
For an alien with a past history of mental illness, the
medical report shall also contain available information on
which the U.S. Public Health Service can base a finding as
to whether the alien has been free of such mental illness for
a period of time, sufficient in the light of such history, to
demonstrate recovery.

Use InfoPass to Make an Appointment.
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.

Applicants With Mental Conditions.

A complete medical history of the alien, including
details of any hospitalization or institutional care or
treatment for any physical or mental condition;

USCIS Forms and Information.

8.

Public Reporting Burden.
A person is not required to respond to a collection of
information unless it displays a currently valid OMB
control number. Public reporting burden for this collection
of information is estimated to average 60 minutes per
response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the
collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of
information, including suggestions for reducing this
burden, to the U.S. Citizenship and Immigration Services,
Regulatory Management Division, 111 Massachusetts
Avenue, N.W., 3rd Floor, suite 3008,Washington, D. C.
20529; OMB No. 1615-0029. Do not mail your
completed application to this address.

Form I-601 Instructions (Rev. 10/26/05)Y Page 2

OMB No. 1615-0029; Expires 01/31/07

I-601, Application for Waiver
of Grounds of Inadmissibility

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

Do not write in this block. For Government use only.
212 (a) (1)
212 (a) (3)
212 (a) (6)
212 (a) (9)

Fee Stamp

212 (a) (10)
212 (a) (12)
212 (a) (19)
212 (a) (23)

A. Information about applicant.
1. Family Name (Surname In CAPS)

11. Applicant was previously in the United States, as follows:
(First)

(Middle)

2. Address (Number and Street)

(Apartment Number)

3. (Town or City)

(Zip/Postal Code)

(State/Country)

Telephone Number

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

City and State

From (Date)

To (Date)

Immigration Status

E-Mail Address

5. USCIS File Number
A-

6. City/Province-State of Birth

7a. Country of Birth

8. Date of Visa Application

7b. Country of
Citizenship/Nationality

9. Visa Applied for at:

10. Applicant was declared inadmissible to the United States for the
following reasons: (List acts, convictions, or physical or mental
conditions. If applicant has active or suspected tuberculosis, Page 3 of
this form must be fully completed. If applicant has HIV infection, Page
3 of this form must be fully completed.)

12. Applicant's U.S. Social Security Number (if any)

B. Information about relative, through whom applicant claims
eligibility for a waiver.
1. Family Name (Surname in CAPS)

2. Address (Number and Street)

Telephone Number

Initial receipt

Resubmitted

5. Immigration Status

Relocated
Received

Copy

(Zip/Postal Code)

E-Mail Address

4. Relationship to Applicant

FOR USCIS USE ONLY. DO
NOT WRITE IN THIS AREA.

(Middle)

(Apartment Number)

(State)

3. (Town or City)

(First)

Completed
Sent

Approved Denied Returned

Form I-601 (Rev. 10/26/05)Y

C. Information about applicant's other relatives in the United
States. (List only U.S. citizens and permanent residents)
1. Family Name (Surname in CAPS)

(First)

(Middle)

2. Address (Number and Street)

(Apartment Number)

3. (Town or City)

(Zip/Postal Code)

(State)

4. Relationship to Applicant

5. Immigration Status

1. Family Name (Surname in CAPS)

(First)

2. Address (Number and Street)

3. (Town or City)

(Middle)

(Apartment Number)

(State)

(Zip/Postal Code)

4. Relationship to Applicant

5. Immigration Status

1. Family Name (Surname in CAPS)

(First)

(Middle)

2. Address (Number and Street)

(Apartment Number)

3. (Town or City)

(Zip/Postal Code)

4. Relationship to Applicant

(State)

5. Immigration Status

CERTIFICATION: Signature (of applicant or petitioning relative)

Relationship to Applicant

Date

PREPARER OF APPLICATION: Signature (of person preparing
application, if not the applicant or petitioning relative). I declare that this
document was prepared by me at the request of the applicant or petitioning
relative, and is based on all information of which I have any knowledge.
Signature

Address

Date

Copy

Form I-601 (Rev. 10/26/05)Y Page 2

To Be Completed for Applicants With
Active Tuberculosis or Suspected Tuberculosis
A. Statement by Applicant.

C. Applicant's Sponsor in the United States.

Upon admission to the United States I will:
Go directly to the physician or health facility named in
Section B;
Present all X-rays used in the visa medical examination to
substantiate diagnosis;
Submit to such examinations, treatment, isolation and
medical regimen as may be required; and
Remain under the prescribed treatment or observation
whether on inpatient or outpatient basis, until discharged.

Arrange for medical care of the applicant and have the physician
complete Section B.
If medical care will be provided by a physician who checked Box 2
or 3, in Section B, have Section D completed by the local or State
Health Officer who has jurisdiction in the United States area where
the applicant plans to reside.
If medical care will be provided by a physician who checked Box
4, in Section B, forward this form directly to the military facility
at the address provided in Section B.
Address in the United States where the alien plans to reside:

Signature of Applicant
Address (Number and Street)

(Apt #)

Date
City, State and Zip Code

B. Statement by Physician or Health Facility.
(May be executed by a private physician, health department,
other public or private health facility or military hospital.)
I agree to supply any treatment or observation necessary for the
proper management of the alien's tuberculosis condition.
I agree to submit Form CDC 75.18, "Report on Alien with
Tuberculosis Waiver," to the health officer named in Section D:

D. Endorsement of Local or State Health Officer.
Endorsement signifies recognition of the physician or facility for
the purpose of providing care for tuberculosis. If the facility or
physician who signed his or her name in Section B is not in your
health jurisdiction and not familiar to you, you may want to contact
the health officer responsible for the jurisdiction of the facility or
physician prior to endorsing.

Within 30 days of the alien's reporting for care, indicating
presumptive diagnosis, test results and plans for future
care of the alien; or

Endorsed by: Signature of Health Officer

30 days after receiving Form CDC 75.18, if the alien has
not reported.

Date

Satisfactory financial arrangements have been made. (This
statement does not relieve the alien from submitting evidence, as
required by consul, to establish that the alien is not likely to
become a public charge.)
I represent (enter an "X" in the appropriate box and give the
complete name and address of the facility below.)
1.
2.
3.
4.

Local Health Department
Other Public or Private Facility
Private Practice
Military Hospital

(Room/Suite Number)

City, State and Zip Code

(Room/Suite Number)

NOTE: If further assistance is needed, contact the
USCIS office with jurisdiction over the intended place
of United States residence of the applicant.

City, State and Zip Code
Signature of Physician

Official Name of Department

Address (Number and Street)

Name of Facility (Please type or print in black ink)
Address (Number and Street)

Enter below the name and address of the Local Health
Department where the "Notice of Arrival of Alien with
Tuberculosis Waiver" should be sent when the alien arrives in the
United States.

Date
Form I-601 (Rev. 10/26/05)Y Page 3

To Be Completed for Applicants With
Human Immunodeficiency Virus (HIV) Infection
A. Statement about applicant.
Upon admission to the United States I will:
1. Go directly to the physician or health facility named in
Section B;
2. Present copies of diagnostic tests used in 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.

Signature of Applicant

C. Applicant's Sponsor in the U.S.
Arrange for medical care of the applicant and have the
physician of facility complete Section B.
If medical care will be provided by a physician who
checked box 2 or 3, in Section B, have Section D
completed by the local or State Health Officer who has
jurisdiction in the area where the applicant plans to reside
in the U.S.
If medical care will be provided by a physician who
checked box 4, in Section B, forward this form directly to
the military facility at the address provided in Section B.
Address where the alien plans to reside in the U.S.:

Date
B. Statement by Physician or Health Facility
(May be executed by a private physician, health department,
or other public or private facility or military hospital.)

Address (Number & Street)

I agree to supply counseling and any treatment or
observation necessary for the proper management of the
alien's HIV infection condition.

City, State, & Zip Code

I agree to submit a copy of my evaluation of the alien's
condition to the health officer named in Section D and to the
Division of Quarentine (E03), Centers for Disease Control
and Prevention (CDC), Atlanta Georgia 30333:
1. Within 30 days of the alien's reporting for care indicating
plans for future care of the alien; or
2. A report that the alien has not reported within 30 days
after receiving a notice from the Division of Quarantine,
CDC.
Satisfactory financial arrangements have been made. (This
statement does not relieve the alien from submitting
evidence, as required by consul, to establish that the alien is
not likely to become a public charge.)
I represent (enter an "x" in the appropriate box and give the
complete name and address of the facility below:)

APT No.

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.
If the facility or physician who signed in Section B is not in
your health jurisdiction and is not familiar to you, you may
wish to contact the health officer responsible for the
jurisdiction of the facility or physician prior to endorsing.
Endorsed by: Signature of Health Officer

Date
Enter below the name and address of the Local Health
Department to which the "Notice of Arrival of Alien with
HIV infection Waiver" should be sent when the alien
arrives in the U.S.
Official Name of Department

1. Local Health Department
2. Other Public or Private Facility
3. Private Practice

Address (Number & Street)

4. Military Hospital

City, State, & Zip Code

APT No.

Name of Physician or Facility (Please type or print)
Address (Number & Street)
City, State, & Zip Code
Signature of Physician
Date

Please read instructions with care.
If further assistance is needed, contact the USCIS office
with jurisdiction over the intended place of U.S. residence
of the applicant.
NOTE: If you are approved for a waiver and after
admission to the U.S. you fail to comply with the terms,
conditions, and controls that were imposed, you may be
subject to removal under Section 237 (a) of the Immigration
and Nationality Act.
Form I-601 (Rev. 10/26/05)Y Page 4

OMB No. 1615-0029; Expires 01/31/07

I-601, Application for Waiver
of Grounds of Inadmissibility

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

Do not write in this block. For Government use only.
212 (a) (1)
212 (a) (3)
212 (a) (6)
212 (a) (9)

Fee Stamp

212 (a) (10)
212 (a) (12)
212 (a) (19)
212 (a) (23)

A. Information about applicant.
1. Family Name (Surname In CAPS)

11. Applicant was previously in the United States, as follows:
(First)

(Middle)

2. Address (Number and Street)

(Apartment Number)

3. (Town or City)

(Zip/Postal Code)

(State/Country)

Telephone Number

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

City and State

From (Date)

To (Date)

Immigration Status

E-Mail Address

5. USCIS File Number
A-

6. City/Province-State of Birth

7a. Country of Birth

8. Date of Visa Application

7b. Country of
Citizenship/Nationality

9. Visa Applied for at:
12. Applicant's U.S. Social Security Number (if any)

10. Applicant was declared inadmissible to the United States for the
following reasons: (List acts, convictions, or physical or mental
conditions. If applicant has active or suspected tuberculosis, Page 3 of
this form must be fully completed. If applicant has HIV infection, Page
3 of this form must be fully completed.)

B. Information about relative, through whom applicant claims
eligibility for a waiver.
1. Family Name (Surname in CAPS)

(Apartment Number)

3. (Town or City)

(Zip/Postal Code)

(State)

E-Mail Address

4. Relationship to Applicant

Initial receipt

(Middle)

2. Address (Number and Street)

Telephone Number

FOR USCIS USE ONLY. DO
NOT WRITE IN THIS AREA.

(First)

Resubmitted

Relocated
Received

AGENCY COPY

5. Immigration Status

Completed
Sent

Approved Denied Returned

Form I-601 (Rev. 10/26/05)Y Page 5

C. Information about applicant's other relatives in the United
States. (List only U.S. citizens and permanent residents)
1. Family Name (Surname in CAPS)

(First)

2. Address (Number and Street)

3. (Town or City)

(Middle)

(Apartment Number)

(State)

(Zip/Postal Code)

4. Relationship to Applicant

5. Immigration Status

1. Family Name (Surname in CAPS)

(First)

(Middle)

2. Address (Number and Street)

(Apartment Number)

3. (Town or City)

(Zip/Postal Code)

(State)

4. Relationship to Applicant

5. Immigration Status

1. Family Name (Surname in CAPS)

(First)

(Middle)

2. Address (Number and Street)

(Apartment Number)

3. (Town or City)

(Zip/Postal Code)

(State)

4. Relationship to Applicant

5. Immigration Status

USCIS Use Only: Additional Information and Instructions

Signature and Title of Requesting Officer

Address

Date

This office will maintain only a folder relating to the applicant
pursuant to A.M. 2712.01

AGENCY COPY

Form I-601 (Rev. 10/26/05)Y Page 6