Form I-191 Form I-191 Application for Advance Permission to Return to Unrelinq

OMB No. 1615-0016; Expires 06/30/2013

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

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

DRAFT

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

From -

ToPresent time

(5) During the past 7 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. 08/20/10)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. 08/20/10)Y Page 2