Form 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. 1615-0123
Expires 03/31/2015

Action Block

Sent

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

Select this box if Form
G-28 is attached to
represent the applicant.

Attorney State Bar Number
(if applicable)

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

► START HERE - Type or print in black ink.

Part 1. Information About You

Your U.S. Mailing Address

Provide the following information about yourself.

7.a. In Care Of Name

1.

Alien Registration Number (A-Number) (if any)
► A-

2.

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

3.

USCIS ELIS Account Number (if any)
►

Your Full Name

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

Other Names Used (if any)
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

Ste.

Flr.

7.d. City or Town
7.e. State
8.

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

4.c. Middle Name

Apt.

7.f.

ZIP Code

Is your current physical address the same as your mailing
address?
Yes
No
If you answered "No" to Item Number 8., provide your
physical address in Item Numbers 9.a. - 9.e.

Your U.S. Physical Address
9.a. Street Number
and Name
9.b.

Apt.

Ste.

Flr.

9.c. City or Town
9.d. State

9.e. ZIP Code

5.c. Middle Name

Other Information
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

10.

Date of Birth (mm/dd/yyyy)

11.

Gender

Male

Female

6.c. Middle Name
Form I-601A 03/04/13 N

Page 1 of 9

Part 1. Information About You (continued)

24.a. From (mm/dd/yyyy)

12.

City or Town of Birth

24.b. To (mm/dd/yyyy)

13.

Country of Birth

14.

Country of Citizenship or Nationality

25.

Immigration Status (at the time of entry)

26.

Are there other previous entries?

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15.b. Mother's Given Name (First Name)

Your Immigration or Criminal History

27.

16.a. Father's Family Name (Last Name)

16.b. Father's Given Name (First Name)

Date of Entry (mm/dd/yyyy)

18.a. Place or Port-of-Entry (City or Town)

18.b. State

If you answered "Yes" to Item Number 27., select the
statement below that most accurately describes your
current situation.

Immigration Status (at the time of entry)

28.a.

Your Previous Entries Into the United States
You were previously in the United States as follows:
20.a. Place or Port-of-Entry (City or Town)

21.a. From (mm/dd/yyyy)
21.b. To (mm/dd/yyyy)
Immigration Status (at the time of entry)

23.a. Place or Port-of-Entry (City or Town)

I am in removal, exclusion, or deportation
proceedings that are administratively closed and, at
the time of filing my Form I-601A, have not been
placed back on EOIR's calendar to continue my
removal, exclusion, or deportation proceedings.
NOTE: Provide a copy of the administrative closure
order. Also, if U.S. Citizenship and Immigration
Services (USCIS) approves your provisional
unlawful presence waiver, you should seek
termination or dismissal of your removal, exclusion,
or deportation proceedings before you depart the
United States for your immigrant visa interview.

20.b. State

22.

Are you currently in removal, exclusion, or deportation
proceedings? This includes being subject to a final order
of removal, exclusion, or deportation or a Department of
Homeland Security (DHS) removal order that reinstates a
prior removal, exclusion, or deportation order.
NOTE: If your case has been administratively closed,
you are still "in removal proceedings" until the
Department of Justice's Executive Office for Immigration
Review (EOIR) terminates or dismisses your case.
However, you are eligible to apply for a provisional
unlawful presence waiver if EOIR has not placed your
removal proceedings back on EOIR's calendar in order to
continue your removal proceeding.
Yes
No

Your Last Entry Into the United States

19.

No

If you answered "Yes" to Item Number 26., include the
place of entry, dates, and your immigration status at the
time of entry for any other prior entries in Part 9.
Additional Information of this application.

15.a. Mother's Family Name (Last Name)

17.

Yes

28.b.

I am subject to a final order of removal, exclusion,
or deportation.

28.c.

I am subject to a DHS order that reinstates a prior
removal, exclusion, or deportation order seeking my
removal, exclusion, or deportation from the United
States.

23.b. State

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Part 1. Information About You (continued)
28.d.

I am currently in removal, exclusion, or deportation
proceedings that are not administratively closed or in
removal, exclusion, or deportation proceedings that
were administratively closed, but EOIR has placed
my proceedings back on its calendar in order to
continue them.

28.e.

I am subject to a judicial order of removal issued by
a Federal Court.

Answer Item Numbers 29. - 35. If you answer "Yes" to any
question in Item Numbers 29. - 35., you may be ineligible for a
provisional unlawful presence waiver if USCIS has reason to
believe that you may be subject to grounds of inadmissibility,
other than unlawful presence under INA section 212(a)(9)(B)(i)(I)
or (II) at the time of your immigrant visa interview with a
Department of State (DOS) consular officer. For each "Yes"
response for Item Numbers 29. - 35., provide the location and
date of the event and a brief description in Part 9. Additional
Information. For Item Number 31., 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 answer "Yes" to Item Number 32., you must provide all
related court dispositions.
29.

30.

31.

Answer Item Numbers 36.a. - 42. If you answer "Yes" to any
question in Item Numbers 36.a. - 42., you may be ineligible for
a provisional unlawful presence waiver if USCIS has reason to
believe that you may be subject to grounds of inadmissibility
other than unlawful presence under INA section 212(a)(9)(B)(i)(I)
or (II) at the time of your immigrant visa interview with a DOS
consular officer. For each "Yes" response for Item Numbers
36.a. - 42., provide a complete explanation in Part 9. Additional
Information.
Have you EVER ordered, incited, called for, committed, assisted,
helped with, or otherwise participated in any of the following:
36.a. Acts involving torture or genocide?

Yes

No

36.b. Killing any person?

Yes

No

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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?
Yes
No
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?
Yes

Yes

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?
Yes
No

33.

Have you EVER trafficked in or are you NOW trafficking
in any controlled substance?
Yes
No

34.

Are you NOW or have you EVER knowingly assisted,
abetted, conspired, or colluded with others in the unlawful
trafficking of any controlled substance?
Yes
No

35.

Are you NOW or have you EVER been engaged in
prostitution?
Yes

No

No

36.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened to
participate or through use of threat?
Yes
No
36.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No

Have you EVER:

37.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
Yes
No

37.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No

38.

Have you EVER been a member of, assisted in, or
participated in any group, unit, or organization of any kind
in which you or other persons used any type of weapon
against any person or threatened to do so?
Yes

No

32.

Form I-601A 03/04/13 N

36.c. Intentionally and severely injuring any person?

No

39.

Have you EVER assisted or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
Yes
No

40.

Have you EVER received any type of military,
paramilitary, or weapons training?
Yes

No

41.

Have you EVER recruited, enlisted, conscripted, or used
any person under 15 years of age to serve in or help an
armed force or group?
Yes
No

42.

Have you EVER used any person under 15 years of age
to take part in hostilities, or to help or provide services to
people in combat?
Yes
No
Page 3 of 9

Part 2. Biographic Information

Immigrant Visa Processing

1.

Petitioner's relationship to you (Select only one box)

2.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino
Race (Select all applicable boxes)
White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

3.
4.
5.

Feet

Weight

3.b.

U.S. Citizen Parent

3.c.

U.S. Citizen Son or Daughter

3.d.

Self (Form I-360 petitioner only)

4.

DOS Consular Case Number (NVC Case Number)
►

5.

Inches

Pounds

Did DOS initially act before January 3, 2013, to schedule
you to appear at a U.S. Embassy or U.S. Consulate for an
immigrant visa interview based on the approved immediate
relative petition listed in Part 3., Item Number 1.?
Yes

Eye Color (Select only one box)
Blue
Green
Pink

Unknown/Other

Black
Gray
White

Blond
Red

Unknown/
Other

Part 3. Information About Your Immediate
Relative Petition and the Processing of Your
Immigrant Application

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

Approved Immediate Relative Petition
USCIS Receipt Number
►

No

NOTE: USCIS may reject or deny your application if
DOS records indicate that DOS initially acted prior to
January 3, 2013, to schedule you for an immigrant visa
interview.

Brown
Hazel

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

1.

U.S. Citizen Spouse

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Height

Black
Gray
Maroon

6.

3.a.

Part 4. Information About Your Qualifying
Relative

Provide the following information about the qualifying relative
(the U.S. citizen spouse or parent) who would experience
extreme hardship if you are refused admission to the United
States or if your qualifying relative chooses to relocate abroad
to live with you.

Your Qualifying Relative's Full Name and
Relationship to You

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.a.

U.S. Citizen Spouse

2.b.

U.S. Citizen Parent

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

Form I-601A 03/04/13 N

Your Other Qualifying Relative
3.

Do you have more than one qualifying relative (U.S. citizen
spouse or parent)?
Yes
No
If you answered "Yes" to Item Number 3., provide the
qualifying relative's name and your relationship to the
qualifying relative in Item Numbers 4.a. - 5.b. Also
provide evidence of the U.S. citizenship of the other
qualifying relative with your application. See the What
Evidence Should I Submit With This Application
section of the Form I-601A instructions.
Page 4 of 9

Part 4. Information About Your Qualifying
Relative (continued)
Additional Qualifying Relative's Full Name and
Relationship to You
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
5.a.
5.b.

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

Part 5. Statement From Applicant

In the space provided, explain in detail why you believe USCIS
should approve your application for a provisional unlawful
presence waiver as a matter of discretion. List all of the reasons
you believe support your application for this waiver, including
information about the extreme hardship your qualifying relatives
would experience if you were refused admission to the United
States. If you need extra space to complete your statement, use
Part 9. Additional Information.

Form I-601A 03/04/13 N

Page 5 of 9

Acknowledgement of Appointment at USCIS
Application Support Center

Part 6. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature

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.

NOTE: Read the information on penalties in the Penalties
section of the Form I-601A Instructions before completing this
part. You must file Form I-601A while in the United States.

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.

1.b.

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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.
The interpreter named in Part 7. 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 7. 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.

2.

I have requested the services of and consented to

,

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.

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)

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 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.
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)

Form I-601A 03/04/13 N

Page 6 of 9

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

Part 7. Interpreter's Contact Information,
Certification, and Signature
Provide the following information concerning the interpreter.

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 reaffirming that the contents of this application and all supporting
documentation are complete, true, and correct.

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

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

2.

Interpreter's Signature

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Interpreter's Business or Organization Name (if any)

6.a. Interpreter's Signature

Interpreter's Mailing Address

6.b. Date of Signature (mm/dd/yyyy)

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Part 8. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant

Flr.

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

3.e. ZIP Code

Provide the following information concerning the preparer.

Province

Preparer's Full Name

3.g. Postal Code

1.a. Preparer's Family Name (Last Name)

3.h. Country

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

Interpreter's Contact Information
4.

5.

2.

Preparer's Business or Organization Name (if any)

Interpreter's Daytime Telephone Number

Preparer's Mailing Address

Interpreter's Email Address (if any)

3.a. Street Number
and Name

Interpreter's Certification

3.b.

I certify that:

3.c. City or Town

I am fluent in English and
which is the same language provided in Part 6., 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 6., 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 6., Item Number 1.b..

Form I-601A 03/04/13 N

Apt.

3.d. State
3.f.

Ste.

Flr.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

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Part 8. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant (continued)
Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number (if any)

6.

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Preparer's Email Address (if any)

Preparer's Statement
7.a.

7.b.

I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.

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, 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 this
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)

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5.a. Page Number

Part 9. 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.

5.b. Part Number

5.c. Item Number

5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

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1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-601A 03/04/13 N

4.c. Item Number

7.a. Applicant's Signature

7.b. Date of Signature (mm/dd/yyyy)

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