Form I-191 Application for advance permission to return to unrelinq

OMB No. 1615-0016; Expires 04/30/07
Department of Homeland Security
U. S. Citizenship and Immigration Services

I-191, Application for Advance Permission
to Return to Unrelinquished Domicile
Instructions

Read the instructions carefully. The fee will not be refunded.

Where to Submit the Application.
This form, when completely executed, should be submitted to the District Director of the District Office of U.S. Citizenship and
Immigration Services (USCIS) having jurisdiction over your place of permanent residence. USCIS is comprised of offices of the
former Immigration and Naturalization Service (INS).

What Is the Fee?
A fee of $265.00 must be paid for filing this application.
The fee cannot be refunded, regardless of the action taken on the application. Do not mail cash. All fees must be submitted in the
exact amount. Payment by check or money order must be drawn on a bank or other institution located in the United States and be
payable in U.S. currency.
If the applicant resides in Guam, the check or money order must be payable to the "Treasurer Guam." If the applicant resides in the
U.S. Virgin Islands, the check or money order must be payable to the "Commissioner of Finance of the Virgin Islands."
All other applicants must make the check or money order payable to the Department of Homeland Security.
When a 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. If the application is submitted from outside the United States, remittance may be made by an international bank money order
or foreign draft drawn on a financial institution in the United States and payable to the Department of Homeland Security in U.S.
currency. Personal checks are accepted subject to collection. An uncollected check will render the application and any document
issued pursuant thereto as invalid. A charge of $30.00 will be imposed if a check in payment of a fee is not honored by the bank on
which it was drawn.
How to Check If the Fee Is Correct.
The fee on this form is current as of the publication date appearing in the lower right corner of this page. However, because USCIS
fees change periodically, you can verify that the fee is correct by following one of the steps below:
Visit our website at www.uscis.gov and scroll down to "Forms and E-Filing" to check the appropriate fees, 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.

Attachments.
If the space provided in the form is insufficient to answer a question fully, you should attach a sheet(s) of paper containing your
response that should be numbered to correspond to the question.

Absences.
In Number 3, where absences have been numerous as a resident alien border crosser or as a seaman, it will be sufficient to give the
approximate number of such absences during the years covered.

Form I-191 (Rev. 10/26/05)Y

Reasons for Inadmissibility.
List specifically and in detail your reasons for possible inadmissibility. For example, if the application is made because the applicant
may be inadmissible due to a conviction of a crime, state in the application the designation of the crime, the date and place of its
commission and of the conviction therefore, and the sentence or other judgement of the court. In the case of a disease, mental or
physical defect or other disability, give an exact description, duration thereof and the date and place last treated.

Exceptions to Execution of the Application.
If the applicant is mentally incompetent or is under 14 years of age, the application shall be executed by his parent or guardian.

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

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.

Our Authority for Collecting This Information.
The authority for collection of the information requested on this form is contained in 8 U.S.C. 1103(a). Submission of the information
is voluntary. The principal purpose for which the information is solicited is for use by a District Director of the U.S. Citizenship and
Immigration Services to determine whether the applicant is eligible for advance permission to return to an unrelinquished domicile
pursuant to the provisions of section 212(c) of the Immigration and Nationality Act, 8 U.S.C. 1182(c).
To elicit further information during the course of an investigation, USCIS may as a matter of routine use in order to carry out its
functions disclose the information to other Federal, state, local, and foreign law enforcement and regulatory agencies, the U.S
Department of Defense, including any component thereof (if the applicant has served, or is serving in the Armed Forces of the United
States), U.S. Department of State, Central Intelligence Agency, Interpol, and individuals and organizations.
Failure to provide any or all of the solicited information may result in the denial of the application.

Reporting Burden.
A person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to
create forms and instructions that are accurate, can be easily understood and that impose the least possible burden on you to provide us
with the information. Often this is difficult because some immigration laws are very complex.
Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about the law and form, and
reading and understanding the form, 5 minutes; 2) completing the form, 5 minutes; 3) assembling and filing the form, 5 minutes; for
an estimated average of 15 minutes per response.
If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, write to the U.S.
Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., Washington, DC 20529,
OMB No. 1615-0016. Do not mail your completed application to this address.

Form I-191 (Rev. 10/26/05)Y Page 2

OMB No. 1615-0016; Expires 04/30/07

I-191, Application for Advance Permission
to Return to Unrelinquished Domicile

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

Fee Stamp

Action Block

Alien Registration Number
Date
(1) I hereby apply for permission to return to the United States under the authority contained in Section 212(c) of the Immigration and Nationality Act.
MY NAME IS:

(First)

(Middle)

(Last)

DATE OF BIRTH: (mm/dd/yyyy) PLACE OF BIRTH: (City, Province, Country)

I AM A CITIZEN/NATIONAL OF: (Country)

PRESENT ADDRESS: (Street and number, apt. no., city, state, country)
(2) I was lawfully admitted to the United States for permanent residence at:
PORT OF ENTRY/DHS OFFICE:

DATE: (mm/dd/yyyy)

NAME OF VESSEL OR OTHER MEANS OF CONVEYANCE:

(3) Since that admission I have departed from and reentered the United States as follows:
DEPARTED FROM THE UNITED STATES
Port

Date
(mm/dd/yyyy)

RETURNED TO THE UNITED STATES

Vessel or Other Means
of Conveyance

PURPOSE OF TRIP

Vessel or Other Means
of Conveyance

Date
(mm/dd/yyyy)

Port

(4) During the past seven years I have resided at the following places: (List present address first)
(Complete Address - Include Apt. No.)

From -

ToPresent time

(5) During the past seven years I have been employed as follows: (List present employment first)
From -

To -

Employer's Name

Occupation or Type of
Business

Address

(6) My immediate family (spouse, unmarried minor children and parents) consists of the following persons:
Name

(7) I

Relation

Date and Country of Birth

Citizen of

depart(ed) temporarily from the United States on or about
(Intend to or have)

and will remain
(Date - mm/dd/yyyy)

in

approximately

, for the purpose of

(Country)

(Length of Time)
; and expect to apply for admission at

Remarks:

Present Address

RECEIVED

TRANS. IN

(Port)
RET'D-TRANS. OUT COMPLETED
Form I-191 (Rev. 10/26/05)Y

(8) I believe I may be inadmissible to the United States for the following reasons:

I understand that the information herein contained may be used in any criminal or civil proceedings, including removal, hereafter instituted against me.
I certify that the statements above are true and correct to the best of my knowledge and belief.

(Signature of Applicant)

Signature of person preparing form, if other than applicant.
I declare that the document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.

(Signature)
Decision:
Application granted upon the following terms and conditions:

(Address)

(Date)
DATE
OF
ACTION
DD
DISTRICT

Form I-191 (Rev. 10/26/05)Y Page 2