I-601A Application for Provisional Unlawful Presence Waiver

Application for Provisional Unlawful Presence Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services

For
USCIS
Use
Only

Initial Receipt

Fee Stamp

Resubmitted

Relocated
Received

USCIS
Form I-601A
OMB No. 1615-XXXX
Expires XX/XX/XXXX

Action Block

Sent

DRAFT
Not for
Production
12/27/2012

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

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

► START HERE - Type or print in black ink.

Part 1. Information About Applicant

5.a. Family Name
(Last Name)

Provide the following information about yourself.

5.b. Given Name
(First Name)

1.

Alien Registration Number (A-Number)
► A-

2.

U.S. Social Security Number (optional)
►

5.c. Middle Name

Home Address (where you physically reside)
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 12/27/12

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)

(
9.

)

Extension

-

E-mail Address (if any)

21.b. State
22.a. Date From (mm/dd/yyyy) ►
22.b. Date To
23.

(mm/dd/yyyy) ►

Immigration Status (at the time of entry)

Birth and Citizenship
(mm/dd/yyyy) ►

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10.

Date of Birth

11.

City or Town of Birth

12.

Province of Birth (if applicable)

24.

Are there other previous entries?

Yes

No

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

Immigration or Criminal History

13.

Country of Birth

14.

Country of Citizenship

25.

Are you currently in removal proceedings (this includes
being subject to a final removal order or to a DHS order
reinstating a prior removal order)?
Yes
No

Note: If you answered "No," skip to Item Number 27.
Note: If your case has been administratively closed, you
are still “in removal proceedings” until the Department of
Justice, Executive Office of Immigration Review (EOIR)
terminates or dismisses your case. However, you are
eligible to apply for a provisional unlawful presence waiver
if EOIR has not recalendared your removal proceeding.

Last Entry Into the United States
15.

Date of Entry (mm/dd/yyyy)►

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

26.

16.b. State
17.

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
19.a. Date From (mm/dd/yyyy) ►
19.b. Date To
20.

(mm/dd/yyyy) ►

Immigration Status (at the time of entry)

Form I-601A 12/27/12

If you answered “Yes” to Item Number 25., select the
statement below that most accurately describes your
current situation:
I am in removal proceedings that are administratively
closed and have not been recalendared at the time of
filing a Form I-601A.
Note: Provide a copy of the administrative closure
notice. You should seek termination or dismissal of your
removal proceedings before you depart the United
States if your application for a provisional unlawful
presence waiver is approved.
I am now subject to a final order of removal, deportation,
or exclusion, or to the reinstatement of a prior removal
order.
I am subject to a DHS order reinstating a prior removal
order.
I am currently in removal proceedings that are not
administratively closed, or I am currently in removal
proceedings that were administratively closed, but
have been recalendared.

Page 2 of 6

27.

28.

29.

30.

Have you ever knowingly and willfully 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?
Yes
No
Have you ever knowingly assisted or attempted to assist
the entry of someone, even a family member, into the
United States without the benefit of a valid travel
document in violation of U.S. law?
No
Yes

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)

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

U.S. Citizen Spouse

Have you ever been charged, indicted, convicted,
imprisoned or jailed in the United States, your home
country, and/or any other country for any crime or
offense?
No
Yes

Self (I-360 petitioner only)

U.S. Citizen Parent

DRAFT
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U.S. Citizen Son or Daughter

Immigrant Visa Processing
4.

Have you ever engaged in, ordered, incited, assisted or
otherwise participated in any of the following:

Consular Case Number (NVC Case Number)
►

31.a. Acts involving torture, genocide, or
human trafficking?

Yes

No

31.b. Killing any person?

Yes

No

31.c. Severely injuring any person?

Yes

No

5.

Note: USCIS may reject or deny your application if you
answer "Yes," do not answer the question, or answer
"No" but DOS records indicate that DOS initially acted
prior to MM/DD/YYYY to schedule you for an immigrant
visa interview.

31.d. Any kind of sexual contact or relations with any person
who was being forced or threatened?
Yes
No

Note: If you answered “Yes” to any item in Item Numbers
27.-31.d., you may be ineligible for a provisional unlawful
presence waiver, and your application may be denied. For each
“Yes” response, provide the location and date of the event, and
a brief description in Part 5., Additional Information, of this
form. For Item Number 29., if you were not charged with any
crime or offense, provide a statement or other documentation
from the arresting authority or prosecutor's office to show that
you were not charged with any crime or offense. If you
answered “Yes” to Item Number 30., you must provide all
related court dispositions.

Part 2. Information About Immediate Relative
Petition and Immigrant Visa Processing
Provide the following information about the approved immediate
relative petition (Form I-130 or I-360) and the related immigrant
visa application.

Did the Department of State initially act before MM/DD/
YYYY to schedule you to appear at a U.S. Embassy or
consulate for an immigrant visa interview based on the
approved immediate relative petition listed in Part 2.,
Item Number 1.?
Yes
No

Part 3. Information About Qualifying Relative

Provide the following information about the U.S. citizen spouse
or parent (qualifying relative) 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
2.

Relationship to Applicant

Approved Visa Petition
1.

USCIS Receipt Number
►

Form I-601A 12/27/12

U.S. Citizen Spouse
U.S. Citizen Parent

Page 3 of 6

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

Do you have more than one qualifying relative (U.S. citizen
spouse or parent)?
Yes
No
If you answered “Yes” provide the name, relationship and
evidence of the U.S. citizenship of the other qualifying
relative in Part 5., Additional Information, of this form.

Part 4. Statement From Applicant
In the space provided, explain in detail why you believe your
application for a provisional unlawful presence waiver should
be approved as a matter of discretion. List all of the reasons
you believe support your application for a provisional unlawful
presence waiver, including information about the extreme
hardship your qualifying relatives would experience if you were
refused admission to the United States.

DRAFT
Not for
Production
12/27/2012

Form I-601A 12/27/12

Page 4 of 6

Part 5. Additional Information
If you need more space to provide any additional information
within this application, please use the space below. If you
require more space than what is provided in this section, you
may use a separate sheet(s) of paper. You must include your
full name on each sheet of paper along with the Page Number,
Part Number, and Item Number related to your explanation.

Part 6. Signature of Applicant (Read the Penalties
section of the instructions before you sign this
application.)
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 unlawful presence waiver.
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.

DRAFT
Not for
Production
12/27/2012
1.a. Signature of Applicant

1.b. Date of Signature (mm/dd/yyyy) ►

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

NOTE: If you are an attorney or BIA-accredited representative,
you must submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, along
with this form.
1.

Attorney or Representative: In the event of a Request for
Evidence (RFE), may USCIS contact you by e-mail?
Yes

No

Preparer's Full Name

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

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

3.

Form I-601A 12/27/12

Preparer's Business or Organization Name

Page 5 of 6

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

Ste.

Flr.

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

4.e. Zip Code

Postal Code

2.a. Signature of Interpreter

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12/27/2012
Interpreter's Information

4.h. Country

3.a. Interpreter's Family Name (Last Name)

Preparer's Contact Information

Preparer's Daytime Phone Number

(
6.

Language Used

2.b. Date of Signature (mm/dd/yyyy) ►

4.g. Province

5.

1.

I certify that I am fluent in English and the language above. I
further certify that I have read each and every question and
instruction on this form, as well as the answer to each question,
to this applicant in the above-mentioned language, and that the
applicant has informed me that he or she has understood each
and every instruction and question of the form, as well as the
answer to each question on the form.

4.a. Street Number
and Name
4.b. Apt.

Part 8. Signature of Interpreter

)

Extension

3.b. Interpreter's Given Name (First Name)

-

Preparer's E-mail Address (if any)

Declaration of Preparer

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.
7.a. Signature
of Preparer

7.b. Date of Signature (mm/dd/yyyy) ►

Form I-601A 12/27/12

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