Form I-690 Form I-690 Application for Waiver of Grounds of Inadmissibility

DRAFT - Not For Production
Form I-690, Application for Waiver
OMB No. 1615-0032; Expires 01/31/12

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

of Grounds of Inadmissibility

For Government Use Only.
Fee Stamp

Fee Receipt Number (This application):

Alien Registration Number (A# of This Applicant):

APPLICANT: Start here. See instructions before completing 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 (08/20/10)Y

Supplement for Applicants With Tuberculosis (TB)
Part A. Applicant's Sponsor in the United States.

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)

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.)
a.
Local Health Department

5.

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)

(Apartment No.)

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 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.
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 United States/adjustment of
status. (Please type or print.)

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

Form I-690 (08/20/10)Y Page 2