I-601A Application for Provisional Unlawful Presence Waiver

USCIS
Form I-601A

Department of Homeland Security
U.S. Citizenship and Immigration Services (USCIS)

OMB No. 1615-XXXX
Expires XX/XX/XXXX

Initial Receipt

Fee Stamp

Resubmitted

Relocated
Received

To Be Completed by an
Attorney or Representative, if any.

► START HERE - Type or print in black ink.

Part 1. Information About Applicant
Provide the following information about yourself.
1.

Alien Registration Number (A-Number)
► A-

2.

Applicant's U.S. Social Security Number (optional)
►

Action Block

DRAFT - Not For Production

For
USCIS
Use
Only

Application for Provisional Unlawful Presence Waiver

Sent

Fill in box if G-28 is attached to represent the applicant.
Attorney State License Number:

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name

Home Address
6.a. Street Number
and Name

6.b. Apt.

Your Full Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name

Other Names Used (if any)
4.a. Family Name
(Last Name)

Ste.

6.c. City or Town
6.d. State

6.e. Zip Code

Mailing Address (if different from Home Address)

7.a. In Care of Name

7.b. Street Number
and Name
7.c. Apt.

Ste.

4.b. Given Name
(First Name)

7.d. City or Town

4.c. Middle Name

7.e. State

Form I-601A 01/26/12

Flr.

Flr.

7.f.

Zip Code

Page 1 of 6

Part 1. Information About Applicant (continued)

21.a. Place or Port of Entry (City or Town)

Contact Information
8.

Daytime Phone Number (if any)

(

-

E-mail Address (if any)

Birth and Citizenship
(mm/dd/yyyy) ►

10.

Date of Birth

11.

City or Town of Birth

12.

Province of Birth (if applicable)

13.

Country of Birth

14.

Country of Citizenship

Last Entry Into the United States
15.

Date of Entry: (mm/dd/yyyy)►

16.a. Place or Port of Entry (City or Town)

22.a. Date From (mm/dd/yyyy) ►
22.b. Date To

Immigration Status (at the time of entry)

Previous Entries Into the United States
Applicant was previously in the United States as follows:
18.a. Place or Port of Entry (City or Town)

18.b. State

23.

Immigration Status (at the time of entry)

24.

Are there other previous entries?

20.

Yes

No

If "Yes," include the place of entry, dates, and immigration
status for previous entries in Part 5 of this Form.

Immigration or Criminal History Records
Answer the questions in Item Numbers 25.a. through 32. by
marking either “Yes” or “No” after each question. You must
answer questions about criminal history records regardless of
the country where the event occurred.
NOTE: If you answer “No” to Items 25.b. or 26.b, or if you
answer “Yes” to Items 27., 28., 29., 30. or 33., you are not
eligible for a provisional unlawful presence waiver and your
application will be denied.
25.a. Are you in removal proceedings?

No

Yes

Note: You many answer “No” if the removal proceedings
have been terminated or dismissed.

Form I-601A 01/26/12

No

Yes

26.b. If you answered “Yes” to Item 26.a, was the NTA
subsequently cancelled by DHS?
Yes

No

27.

Are you subject to a final order of removal, deportation,
or exclusion, or to the reinstatement of a prior removal
order?
No
Yes

28.

Have you ever given false or misleading information to a
U.S. Government official while applying for an
immigration benefit or to gain entry or admission into the
United States?
No
Yes

(mm/dd/yyyy) ►

Immigration Status (at the time of entry)

Note: If you answered “Yes” to Item 25.b, you will need
to provide a copy of the administrative closure notice and
voluntary departure order.

26.a. Have you ever been issued a Notice to Appear (NTA)?

19.a. Date From (mm/dd/yyyy) ►
19.b. Date To

(mm/dd/yyyy) ►

25.b. If you answered “Yes” to Item 25.a, were your removal
proceedings administratively closed but subsequently
reopened for voluntary departure?
No
Yes

16.b. State
17.

21.b. State

DRAFT - Not For Production

9.

)

Extension

Page 2 of 6

29.

Have you ever assisted the entry of someone, even a
family member, into the United States without the benefit
of a valid travel document?
No
Yes

Part 2. Information About Immediate Relative
Petition and Consular Visa Processing

30.

Have you ever committed a crime for which you were not
arrested?
No
Yes

Provide the following information about the approved immediate
relative petition (Form I-130 or I-360) and your immigrant visa
application:

31.

Have you ever been arrested, cited, or detained by a law
enforcement officer (including immigration and military
officers) for any reason other than traffic violations in the
United States, your home country, and/or any other
country?
No
Yes

DRAFT - Not For Production

32.

Have you ever been charged, indicted, imprisoned or
jailed for any crime or offense?
No
Yes

33.

If you answered “Yes” to Item Numbers 31. or 32., were
you ever convicted of a crime?
No
Yes
Note: If you were convicted of a crime, you must answer
“Yes” even if your records were expunged; you were
placed in an alternative sentencing or rehabilitation
program (for example: diversion, deferred prosecution,
withheld adjudication, deferred adjudication); your
records were sealed or otherwise cleared; or if anyone,
including a judge, law enforcement officer, or attorney,
told you that you no longer have a record.

If you answered “Yes” to Item Numbers 31. or 32., provide the
location and date of the event, and a brief description below for
each event. If you require additional space, use Part 5 of this
Form. You must provide all related court dispositions to
show that you were not convicted of a crime.

1.

34.b. State
34.c. Country

►

34.e. Brief description of arrest or detainment

USCIS Receipt Number
►

Petitioner's Full Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
3.

Petitioner's Relationship to Applicant (Select only one)
U.S. Citizen Spouse

U.S. Citizen Parent

U.S. Citizen Son or Daughter
Self (I-360 petitioner only)

Consular Visa Processing
4.

Consular Case Number (NVC Case Number)
►

5.

34.a. City or Town

34.d. Date (mm/dd/yyyy)

Approved Visa Petition

Did the Department of State already schedule you to
appear at a U.S. Embassy or consulate for an immigrant
visa interview?
Yes
No
If “Yes,” then you are not eligible to apply for a
provisional unlawful presence waiver prior to your
immigrant visa interview.

Part 3. Information About Qualifying Relative

Provide the following information about the qualifying relative
(U.S. citizen spouse or parent) who would experience extreme
hardship if you were refused admission to the United States:
Qualifying Relative's Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Form I-601A 01/26/12

Page 3 of 6

Part 3. Information About Qualifying Relative
(continued)
2.

Relationship to Applicant
U.S. Citizen Spouse

Do you have more than one qualifying relative (U.S.
citizen spouse or parent)?
No
Yes
If "Yes," include the name and relationship of the other
qualifying relatives in Part 5 of this Form.

Part 4. Statement From Applicant
In the space provided, describe in detail all of the reasons
that you believe support your request for a waiver, including
information about the extreme hardship your qualifying
relative(s) would experience if you were refused admission
to the United States.

Form I-601A 01/26/12

DRAFT - Not For Production

3.

U.S. Citizen Parent

Page 4 of 6

Part 5. Additional Information

Part 6. Signature of Applicant

In the space provided, you may add additional information
regarding any item in this form. In order to assist USCIS in
reviewing your response, you must indicate the Part Number
and Item Number of this form which relates to the additional
information.

I certify, under penalty of perjury under the laws of the United
States, that this application and the evidence submitted with it
are all true and correct to the best of my knowledge and abilities.
I authorize the release of any information from my records that
U.S. Citizenship and Immigration Services (USCIS) needs to
determine my eligibility for this provisional waiver.

DRAFT - Not For Production

I further authorize release of information contained in this form,
supporting documents, and my USCIS records to other entities
and persons where necessary for the administration of the U.S.
immigration laws.

1.a. Signature of Applicant

1.b. Date of Signature (mm/dd/yyyy) ►

Part 7. Signature of Person Preparing This
Application (if other than the applicant)

NOTE: If you are an attorney or representative, you must submit
a completed Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, along with this application.

Preparer's Full Name

Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name

Preparer's Mailing Address

3.a. Street Number
and Name

3.b. Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

3.e. Zip Code

Postal Code

3.g. Province
3.h. Country

Form I-601A 01/26/12

Page 5 of 6

Part 7. Signature of Person Preparing This
Application (continued)
Preparer's Contact Information
4.

Preparer's Daytime Phone Number

5.

)

-

Preparer's E-mail Address (if any)

Declaration of Preparer

DRAFT - Not For Production

(

Extension

I declare that this document was prepared by me at the request of
the applicant and it is based on all information of which I have
knowledge and/or was provided to me by the above named person
in response to the exact questions contained on this form. I have
not knowingly withheld any information or provided responses
for the applicant.
6.a. Signature
of Preparer
6.b. Date of Signature (mm/dd/yyyy) ►

Form I-601A 01/26/12

Page 6 of 6