I-212 Form TOC

TABLE OF CHANGES - FORM

Form I-212, Application for Permission to Reapply for Admission Into the United States After Deportation or Removal

OMB No 1615-0018

Date: 05/03/2015

Reason for Revision: Subject matter updates, standard language updates, and reformatting.

Current Location	Current Text	Location and Proposed Text
Page 1	Applicants Start Here (To be filed in duplicate)	START HERE - Type or print in black ink.
Page 1, Part I. Information About You	[Page 1] PART I. INFORMATION ABOUT YOU Alien registration number (A#) if known, or Alien File(s) or receipt number(s) and any immigration file(s) or case number(s) listed on correspondence from U.S. immigration authorities that relate to you Last Name First Name Middle Name Other names used or known by Name used when last deported or removed from the United States Date of Birth Place of Birth (City or Town) State Province Country Country of Citizenship or Nationality	[Page 1] Part 1. Information About You 1. Alien Registration Number (A-Number) (if any) Your Full Name 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Other Names Used List all other names you have ever used, including maiden names, aliases, and nicknames. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Mailing Address NOTE: If you are outside the United States, provide a U.S. mailing address, if available. If a U.S. mailing address is not available, provide your mailing address abroad. 4.a. In Care Of Name 4.b. Street Number and Name 4.c. Apt. Ste. Flr. 4.d. City or Town 4.e. State 4.f. ZIP Code 4.g. Province 4.h. Postal Code 4.i. Country 5. Is your mailing address the same address where you currently live (physical address)? Y/N If you answered "No" to Item Number 5., provide your current physical address in Item Numbers 6.a. - 6.h. [Page 2] Physical Address 6.a. Street Number and Name 6.b. Apt. Ste. Flr. 6.c. City or Town 6.d. State 6.e. ZIP Code 6.f. Province 6.g. Postal Code 6.h. Country Other Information About You 7. U.S. Social Security Number (if any) 8. Gender M/F 9. Date of Birth (mm/dd/yyyy) 10. City or Town of Birth 11. State or Province of Birth (if applicable) 12. Country of Birth 13. Country of Citizenship or Nationality If you seek an immigrant or nonimmigrant visa and you are or will file your application for consent to reapply with your immigrant or nonimmigrant visa application, provide the information requested in Item Numbers 14.a. – 14.b. 14.a. The Department of State (DOS) Consular Case Number (if available) 14.b. The location of the U.S. Embassy or U.S. Consulate where your application for an immigrant visa is being or will be made City Country If you are seeking consent to reapply in connection with your application to adjust your status to that of a lawful permanent resident, provide information in Item Numbers 15.a. - 15.c. 15.a. USCIS Receipt Number (if any) 15.b. Where did you file your application (for example, “USCIS Office Name” or “Lockbox”)? 15.c. Date Filed (mm/dd/yyyy) 16. Are you submitting Form I-601, Application for Waiver of Grounds of Inadmissibility, along with this application? Yes No If you answered “No,” provide the information requested below about previously filed Forms I-601 (if any): 17.a. USCIS Receipt Number for Form I-601 (if any) 17.b. Where did you file your application (for example, “USCIS Office Name” or “Lockbox”)? 17.c. Date Filed (mm/dd/yyyy)
Page 1, Part II. Reason for Filing This Form	[Page 1] PART II. REASON FOR FILING THIS FORM I am inadmissible to the United States for the following reason(s) and no others: I have been removed as an arriving alien in expedited removal proceedings under INA section 235(b)(1), or I was removed at the end of proceedings under INA section 240 as an arriving alien (INA section 212(a)(9)(A)(i)). I have only been removed once, and my last removal was less than 5 years ago. I have been removed at least twice or more, and my last removal was less than 20 years ago. I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the United States). I have been removed as a deportable alien under INA section 240 or any other provision of the law, or I departed the United States while an order or removal was outstanding (INA section 212(a)(9)(A)(ii)). I have only been removed once and less than 10 years ago. I have been removed at least twice or more, and my last removal was less than 20 years ago. I have been convicted of an aggravated felony (in the United States or elsewhere, before or after my removal from the United States). [Page 2] I entered or attempted to enter the United States without being admitted or paroled after having been removed (INA section 212(a)(9)(C)(i)(I)). Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the date of your last departure from the United States and that you have remained outside the United States for 10 years.) I entered or attempted to enter the United States without being admitted or paroled after having been unlawfully present in the United States for a period of more than 1 year, in the aggregate (INA section 212(a)(9)(C)(i)(I)). Specify date of last departure from the United States after having become inadmissible: (Attach evidence that demonstrates the date of your last departure from the United States and that you have remained outside the United States for 10 years.)	[Page 2] Part 2. Reasons You Are Filing Form I-212 If you are inadmissible to the United States for the following reason, select “Yes” and then select the appropriate boxes. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. Removal as an Arriving Alien (INA section 212 (a)(9)(A)(i)) 1.a. I have been removed as an arriving alien in expedited removal proceedings under INA section 235(b)(1) or I was removed at the end of proceedings under INA section 240 as an arriving alien. Y/N 1.b. I have only been removed once, and my last removal was less than five years ago. 1.c. I have been removed at least two or more times, and my last removal was less than 20 years ago. 1.d. I have been convicted of an aggravated felony in the United States or abroad, before or after my removal from the United States. Provide information on your aggravated felony convictions in Part 8. Additional Information and include the required evidence. [Page 3] 2.a. Date you were removed from the United States (mm/dd/yyyy) 2.b. Location from where you were removed City or Town State Removal as a Deportable Alien (INA section 212(a)(9)(A)(ii)) 3.a. I have been removed as a deportable alien under INA section 240 or any other provision of the law, or I departed the United States while an order of removal was outstanding. Y/N 3.b. I have only been removed once and my removal was less than 10 years ago. 3.c. I have been removed two or more times, and my last removal was less than 20 years ago. 3.d. I have been convicted of an aggravated felony in the United States or abroad, before or after my removal from the United States. Provide information on your aggravated felony convictions in Part 8. Additional Information and include the required evidence. 4.a. Date you were excluded, deported, or removed from the United States (mm/dd/yyyy) 4.b. Location from where you were removed City or Town State Entry After Unlawful Presence in the Aggregate of 1 Year (INA section 212(a)(9)(C)(i)(I)) 5.a.  I entered or attempted to enter the United States without being admitted or paroled, after having been unlawfully present in the United States on or after April 1, 1997, for a period of more than one year, in the aggregate. Y/N NOTE: If you answered “Yes” to Item Number 5.a., list all the time periods during which you were unlawfully present in the United States (including any periods in which you overstayed your lawful status). Begin with your most recent period of unlawful presence. Also attach evidence demonstrating that you have remained outside the United States for 10 years since your last departure. Periods of Unlawful Presence 5.b. From (mm/dd/yyyy) 5.c. To (mm/dd/yyyy) 6.a. Date you departed the United States after your period of unlawful presence (mm/dd/yyyy) 6.b. Location where you departed the United States after your period of unlawful presence City or Town State 6.c. Location where you reentered or attempted to reenter the United States City or Town State 6.d. Date you attempted to unlawfully enter or reenter the United States after period of unlawful presence (mm/dd/yyyy) Entry After Removal (INA section 212(a)(9)(C)(i)(II)) 7.a.  I entered or attempted to enter the United States without being admitted or paroled after having been excluded, deported, or removed. Y/N NOTE: If you answered “Yes” to Item Number 7.a., list all the dates when you were excluded, deported, or removed from the United States. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 7.b. Date you were excluded, deported, or removed from the United States (mm/dd/yyyy) 8.a. Location where you reentered or attempted to reenter the United States after your exclusion, deportation, or removal City or Town State 8.b. Date you entered or attempted to reenter the United States after exclusion, deportation, or removal (mm/dd/yyyy)
Page 2, Part III., Information About Your Removal/ Deportation and Departure	PART III. INFORMATION ABOUT YOUR REMOVAL/DEPORTATION AND DEPARTURE Date of deportation or removal from the United States If you have not been in removal proceedings, date of last departure from the United States (Attach evidence) Length of residence in the United States (years) Place of residence at time of deportation or removal from United States (city and state) Place deportation or removal hearing held or application for removal made (city and state) Country to which deported or removed Detention facility or jail where detained (city and state) (If not detained, write "None.") Port/location of departure from the United States	[Deleted]
Page 2-3, Part IV. Reason(s) For Your Request For Permission to Reapply	[Page 2] PART IV. REASON(S) FOR YOUR REQUEST FOR PERMISSION TO REAPPLY Status desired if permitted to reenter the United States: Permanent Resident Visitor Student Other (specify) Reason(s) for desiring to reenter the United States [Page 3] Location of U.S. Embassy/ consulate where application for visa will be made Name and relationship of U.S. citizen or lawful permanent resident alien spouse, parent or child, if any	[Page 4] Part 3. Reasons For Your Request For Permission to Reapply If the Department of Homeland Security (DHS) permits you to reenter the United States, what immigration status will you seek? 1.a. Permanent Resident 1.b. Visitor 1.c. Student 1.d. Other (Explain) 2. Explain why you would like to reenter the United States NOTE: If you need extra space to complete this section, use the space provided in Part 8. Additional Information. [Deleted] U.S. Citizen or Lawful Permanent Resident Family Members (if any) NOTE: If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 3.d. Relationship My relative is (Select one): 4.a. Aa lawful permanent resident. 4.b. A U.S. citizen.
New		[Page 4] Part 4. Biographic Information 1.  Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 2.  Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 3.  Height  Feet Inches 4.  Weight    Pounds 5.  Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6.  Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Page 3, Part V. Applicant’s Signature and Certification	[Page 3] PART V. APPLICANT'S SIGNATURE AND CERTIFICATION Applicant's Telephone Number Applicant's Mobile Telephone Number Applicant's E-mail Address (if any) 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) or any other agency adjudicating this application needs to determine my eligibility for the benefits sought with this application. Signature of Applicant or Legal Guardian Date of Signature Applicant's Street Address (You must provide a physical address.) City State Zip Code Province P.O. Box (If applicable) State Province Country	[Page 4] Part 5. Applicant’s Statement, Contact Information, Certification, Acknowledgement of Appointment at USCIS Application Support Center, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-212 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. I can read and understand English, and have read and understand every question and instruction on this application, as well as my answer to every question. I have read and understand the Acknowledgement of Appointment at USCIS Application Support Center. 1.b. The interpreter named in Part 6. has read to me every question and instruction on this application, as well as my answer to each question, in [Fillable Field], a language in which I am fluent.  I understand each and every question and instruction on this application as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above. The interpreter named in Part 6. has also read the Acknowledgement of Required Appointment at USCIS ASC to me, in the language in which I am fluent, and I understand this Application Support Center (ASC) Acknowledgement as read to me by my interpreter. 2. I have requested the services of and consented to [Fillable Field], who is/is not an attorney or accredited representative, preparing this application for me. This person who assisted me in preparing my application has reviewed the Acknowledgement of Appointment at USCIS Application Support Center with me, and I understand the ASC Acknowledgement. [Page 5] Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4 Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) Acknowledgement of Appointment at USCIS Application Support Center I, [Auto-populate Field with Applicant's Full Name], understand that the purpose of a USCIS ASC appointment is for me to provide fingerprints, photograph, and/or signature and to re-affirm that all of the information in my application is complete, true, and correct and was provided by me. I understand that I will sign my name to the following declaration which USCIS will display to me at the time I provide my fingerprints, photograph, and/or signature during my USCIS ASC appointment. I declare under penalty of perjury that I have reviewed and understand my application, petition, or request as identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with my application, petition, or request that I (or my attorney or accredited representative) filed with USCIS, and that all of the information in these materials is complete, true, and correct. I also understand that when I sign my name, provide my fingerprints, and am photographed at the USCIS ASC, I will be re-affirming that I willingly submit this application; I have reviewed the contents of this application; all of the information in my application and all supporting documents submitted with my application were provide by me and are complete, true, and correct; and if I was assisted in completing this application, the person assisting me also reviewed this Acknowledgement of Appointment at USCIS Application Support Center with me. Applicant’s Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek [or my request for deferred action]. I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. I certify, under penalty of perjury, that the information in my application and any document submitted with my application were provided by me and are complete, true, and correct. Applicant’s Signature 6.a. Applicant’s Signature 6.b. Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the instructions, USCIS may deny your application. [Deleted]
New		[Page 5] Part 6. Interpreter’s Contact Information , Certification, and Signature Provide the following information concerning the interpreter. Interpreter’s Full Name 1.a. Interpreter’s Family Name (Last Name) 1.b. Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name (if any) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country [Page 6] Interpreter’s Contact Information 4. Interpreter’s Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification I certify that: I am fluent in English and [Fillable Field], which is the same language provided in Part 5., Item Number 1.b.; I have read to this applicant every question and instruction on this application, as well as the answer to every question, in the language provided in Part 5., Item Number 1.b.; and I have read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant in the same language provided in Part 5., Item Number 1.b. The applicant has informed me that he or she understands every instruction and question on the application, as well as the answer to every question, and the applicant verified the accuracy of every answer; and The applicant has also informed me that he or she understands the ASC Acknowledgement and that by appearing for a USCIS ASC biometric services appointment and providing his or her fingerprints, photograph, and/or signature, he or she is re-affirming that the contents of this application and all supporting documentation are complete, true, and correct. Interpreter’s Signature 6.a. Interpreter’s Signature 6.b. Date of Signature (mm/dd/yyyy)
Page 3, Part VI. Preparer’s Signature and Certification (If other than applicant)	[Page 3] PART VI. PREPARER'S SIGNATURE AND CERTIFICATION (If other than applicant) Preparer's Telephone Number Preparer's Mobile Telephone Number Preparer's E-mail Address (if any) I declare that this document was prepared by me at the request of the applicant or legal guardian of the applicant, and that 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. Signature of Preparer Date of Signature Preparer's Street Address City State Zip Code Province P.O. Box (If applicable) State Province Country	[Page 6] Part 7. Contact Information, Statement, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant Provide the following information concerning the preparer: Preparer’s Full Name 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country Preparer’s Contact Information 4. Preparer’s Daytime Telephone Number [Deleted] 5. Preparer’s Fax Number (if any) 6. Preparer’s Email Address (if any) [Page 7] Preparer’s Statement 7.a. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant’s consent. 7.b. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States, with this application. Preparer’s Certification By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this application on behalf of, at the request of, and with the express consent of the applicant. I completed this application based only on responses the applicant provided to me. After completing the application, I reviewed it and all of the applicant’s responses with the applicant, who agreed with every answer on the application. If the applicant supplied additional information concerning a question on the application, I recorded it on the application. I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant and the applicant has informed me that he or she understands the ASC Acknowledgement. Preparer’s Signature 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy) [Deleted]
New		[Page 8] Part 8. Additional Information If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Include your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Narrative space] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Narrative space] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Narrative space] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Narrative space] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Narrative space] 8.a Signature 8.b. Date of Signature (mm/dd/yyyy)

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