Form I-690 Application for Waiver of Grounds of Inadmissibility

Application for Waiver of Grounds of Inadmissibility

USCIS
Form I-690

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

OMB No. 1615-0032
Expires 03/31/2017

DRAFT
NOT FOR
REPRODUCTION
For Government Use Only

Alien Registration Number (A-Number of This Applicant):
A-

Action Block

Fee Receipt Number (This application):

Select this box if
Form G-28 is
attached.

To be completed by an
attorney or accredited
representative (if any).

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS ELIS Account Number (if any)

► APPLICANT: Start here. Type or print in black ink. Read the instructions before completing this application. If you need extra
space to complete any item within this application, use Part 6. Additional Information or attach a separate sheet of paper; type or
print your name and Alien Registration Number (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.

Part 1. Information About You (the Applicant)
Your Current Legal Name
1.

Family Name (Last Name)

Mailing Address
2.

Middle Name (if applicable)

03/24/2015

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

Given Name (First Name)

Postal Code

ZIP Code

Country

Is your current mailing address the same as your physical address?

Yes

No

If you answered "No" to Item Number 3., provide your physical address in Item Number 4.

Form I-690 03/16/15 N

Page 1 of 8

Part 1. Information About You (the Applicant) (continued)
Physical Address
4.

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NOT FOR
REPRODUCTION

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Other Information
5.

City/Town/Village of Birth

7.

Date of Birth (mm/dd/yyyy)

6. Country of Birth

8.

Alien Registration Number (if any)
► A-

9.

USCIS ELIS Account Number (if any)
►

10. U.S. Social Security Number (if any)
►

Part 2. Additional Information About You
1.

Date Primary Application Filed (mm/dd/yyyy) ►

2.

Type of Primary Application

3.

Relating Receipt Number

4.

I am applying for a waiver of (Select all that apply):

Permanent Residence (Form I-698)

Temporary Residence (Form I-687 or Form I-700)

03/24/2015
►

INA section (Please see the instructions for more information on these sections)
212 (a) (1)(A)(i), (ii), (iii) or (iv)
212 (a)(2)(A)(i)(II)
212 (a)(6)(A)(i)
212(a)(6)(D) and/or (E)

212(a)(8)(A) and/or (B)

212(a)(9)(B)(i)(I) or (i)(II)

212(a)(9)(C)(i)(I) or (i)(II)

212(a)(6)(C)(i) or (ii)

212(a)(9)(A)(i) or (ii)

212 (a)(10)(A), (B), (C), (D) and/or Other Inadmissibility - Specify below

5.

List specific reasons for inadmissibility.

Form I-690 03/16/15 N

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Part 2. Additional Information About You (continued)
6.

List all immediate relatives in the United States (Parents, spouse, and children). If you need more space, use Part 6. Additional
Information or attach an additional sheet.

DRAFT
NOT FOR
REPRODUCTION

A. Your Relative's Information
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy) Relationship

A-Number (if any)
► A-

ZIP Code

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status,
deferred action recipient)

B. Your Relative's Information
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

03/24/2015

Date of Birth (mm/dd/yyyy) Relationship

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status,
deferred action recipient)

C. Your Relative's Information
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy) Relationship

A-Number (if any)

ZIP Code

► AImmigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status,
deferred action recipient)

Form I-690 03/16/15 N

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Part 2. Additional Information About You (continued)
D. Your Relative's Information
Family Name (Last Name)

DRAFT
NOT FOR
REPRODUCTION
Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy) Relationship

A-Number (if any)

ZIP Code

► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status,
deferred action recipient)

7.

I should be granted a waiver because: (Describe family unity considerations or humanitarian or public interest reasons for
granting a waiver. If you need more space, Part 6. Additional Information or attach a separate sheet of paper; type or print
your name and Alien Registration Number (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.

Part 3. Applicant's Statement, Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature

03/24/2015

NOTE: Read the information on penalties in the Penalties section of the Form I-690 Instructions before completing this part.

Applicant's Statement

NOTE: Select the box for either Item Number A. or B. If applicable, select the box for Item Number 2.
1.

2.

Applicant's Statement Regarding the Interpreter
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.

B.

The interpreter named in Part 4. has also read to me every question and instruction on this application, as well as my
answer to every question, in
, a language in which I am fluent.
I understand 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 4. has also read
the Acknowledgement of Appointment at USCIS Application Support Center 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.

Applicant's Statement Regarding the Preparer
,
I have requested the services of and consented to
is
is not an attorney or accredited representative, preparing this application for me. This person who assisted me
who
in preparing my application has reviewed the Acknowledgement of Appointment at USCIS Application Support Center
with me, and I understand the ASC Acknowledgement.

Form I-690 03/16/15 N

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Part 3. Applicant's Statement, Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature (continued)

DRAFT
NOT FOR
REPRODUCTION

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

4. Applicant's Mobile Telephone Number (if any)

Acknowledgement of Appointment at USCIS Application Support Center
I,

,

understand that the purpose of a USCIS ASC appointment is for me to provide my 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 ASC appointment:
By signing here, 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 provided 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.

Applicant's Certification

03/24/2015

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.
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.

Applicant's Signature

Date of Signature
(mm/dd/yyyy)

Part 4. Interpreter's Contact Information, Certification, and Signature
Provide the following information concerning the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Form I-690 03/16/15 N

Interpreter's Given Name (First Name)

Page 5 of 8

Part 4. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

DRAFT
NOT FOR
REPRODUCTION

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

Interpreter's Certification
I certify that:

, which is the same language provided in Part 3.,

I am fluent in English and

Item B., in Item Number 1.

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 3., Item B., in Item Number 1.; and
I have read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant, in the same language
provided in Part 3., Item B., Item Number 1. 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.

Interpreter's Signature

03/24/2015
Date of Signature
(mm/dd/yyyy)

Part 5. 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.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Form I-690 03/16/15 N

Preparer's Given Name (First Name)

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Part 5. Contact Information, Statement, Certification, and Signature of the Person Preparing this
Application, If Other Than the Applicant (continued)

DRAFT
NOT FOR
REPRODUCTION

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5. Preparer's Fax Number (if any)

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 (choose one)

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 Attorney or Accredited Representative, with this petition.

03/24/2015

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.

Preparer's Signature

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, your application may be denied.
NOTE: We recommend that you print a copy of your completed application for your records. If you are required to appear for a
biometric services appointment at a USCIS ASC, you should bring a copy of your completed application with you.

Form I-690 03/16/15 N

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Part 6. Additional Information
If you need extra space to provide any additional information within this application, use the space below or attach a separate sheet of
paper. 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.

DRAFT
NOT FOR
REPRODUCTION

1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.A. Page Number

3.D.

4.A. Page Number

3.B. Part Number

4.B. Part Number

Given Name (First Name)

Middle Name

3.C. Item Number

4.C. Item Number

4.D.

5.A. Page Number

03/24/2015

5.B. Part Number

5.C. Item Number

6.B. Part Number

6.C. Item Number

5.D.

6.A. Page Number

6.D.

7.

Signature

Form I-690 03/16/15 N

Date of Signature
(mm/dd/yyyy)

Page 8 of 8