I-601A Form TOC

TABLE OF CHANGES – FORM

Form I-601A, Application for Provisional Unlawful Presence Waiver

OMB Number: 1615-0123

08/17/2015

Reason for Revision: Executive Action Memorandum From November 20, 2014, directing USCIS to expand the Provisional Unlawful Presence Waiver Program to all immigrant relatives having a visa immediately available.

Current Section and Page Number	Current Text	Proposed Text
Page 1, Attorney or BIA-Accredited Representative	[Page 1] 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)	[Page 1] [no change]
Page 1-3, Part 1. Information About You	[Page 1] START HERE - Type or print in black ink. Part 1. Information About You Provide the following information about yourself. 1. Alien Registration Number (A-Number) (if any) 2. U.S. Social Security Number (if any) 3. USCIS ELIS Account Number (if any) Your Full Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Names Used (if any) 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name Your U.S. Mailing Address 7.a. In Care Of Name 7.b. Street Number and Name 7.c. Apt. Ste. Flr. 7.d. City or Town 7.e. State 7.f. ZIP Code 8. Is your current physical address the same as your mailing address? Y/N 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 Other Information 10. Date of Birth (mm/dd/yyyy) 11. Gender Male/Female [Page 2] 12. City or Town of Birth [Delete] 13. Country of Birth 14. Country of Citizenship or Nationality 15.a. Mother’s Family Name (Last Name) 15.b. Mother’s Given Name (First Name) 16.a. Father’s Family Name (Last Name) 16.b. Father’s Given Name (First Name) Your Last Entry Into the United States 17. Date of Entry (mm/dd/yyyy) 18.a. Place or Port-of-Entry (City or Town) 18.b. State 19. Immigration Status (at the time of entry) 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) 20.b. State 21.a. From (mm/dd/yyyy) 21.b. To (mm/dd/yyyy) 22. Immigration Status (at the time of entry) 23.a. Place or Port of Entry (City or Town) 23.b. State 24.a. From (mm/dd/yyyy) 24.b. To (mm/dd/yyyy) 25. Immigration Status (at the time of entry) 26. Are there other previous entries? Y/N 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. Your Immigration or Criminal History 27. 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. If you answered “Yes” to Item Number 27., select the statement below that most accurately describes your current situation. Y/N 28.a. 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 EIOR’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. 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. [Page 3] 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. 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? Y/N 30. 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? Y/N 31. 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? Y/N 32. 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? Y/N 33. Have you EVER trafficked in or are you NOW trafficking in any controlled substance? Y/N 34. Are you NOW or have you EVER knowingly assisted, abetted, conspired, or colluded with others in the unlawful trafficking of any controlled substance? Y/N 35. Are you NOW or have you EVER been engaged in prostitution? Y/N 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? Y/N 36.b. Killing any person? Y/N 36.c. Intentionally and severely injuring any person? Y/N 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? Y/N 36.e. Limiting or denying any person’s ability to exercise religious beliefs? Y/N Have you EVER: 37.a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerilla group, militia, or insurgent organization? Y/N 37.b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons? Y/N 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? Y/N 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? Y/N 40. Have you EVER received any type of military, paramilitary, or weapons training? Y/N 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? Y/N 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? Y/N	[Page 1] START HERE - Type or print in black ink. Part 1. Information About You [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] 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 the space provided in Part 9. Additional Information. [no change] [no change] [no change] [no change] [no change] [no change] 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 the space provided 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. [no change] [no change] [no change] [no change] [no change] [no change] [no change] 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 the space provided in Part 9. Additional Information. [no change] [no change] [no change] [no change] 36.d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened? Y/N [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change]
Page 4, Part 2. Biographic Information	[Page 4] Part 2. 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 4] Part 2. Biographic Information [no change] [no change] [no change] [no change] [no change] [no change]
Page 4, Part 3. Information About Your Immediate Relative Petition and the Processing of Your Immigrant Application	[Page 4] 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 I-360) and the related immigrant visa application. Approved Immediate Relative Petition 1. USCIS Receipt Number 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name Immigrant Visa Processing Petitioner’s relationship to you (Select only one box) 3.a. U.S. Citizen Spouse 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. 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.? Y/N 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.	[Page 4] Part 3. Information About Your Immigrant Visa Petition and Your Immigrant Visa Case Provide the following information about the approved immigrant visa petition (Form I-130, Form I-140, or Form I-360) that is your basis to immigrate and the related Department of State (DOS) immigrant visa application. If you are a Diversity Visa (DV) Program selectee or a DV Program derivative, provide information about your (or your spouse’s or parent’s) DV case. Approved Immigrant Visa Petition [no change] [no change] 3. Company or Organization Name Immigrant Visa Processing [delete] 4.a. DOS Consular Case Number (NVC Case Number) 4.b. DOS DV Case Number (KCC Case Number) [14 digit box] 5.a. If you are an immediate relative of a U.S. citizen, 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 immigrant visa petition listed in Part 3., Item Number 1.? Y/N NOTE: USCIS may reject or deny your application if you answer “Yes,” do not answer this question, or answer “No” but DOS records indicate that DOS initially acted before January 3, 2013 to schedule you for an immigrant visa interview. 5.b. If you are an immigrant other than an immediate relative of a U.S. citizen, did DOS initially act before [Date TBD] to schedule you to appear at a U.S. Embassy or U.S. Consulate for an immigrant visa interview based on the approved immigrant visa petition in Part 3., Item Number 1. or based on the DOS DV Case Number listed in Part 3., Item Number 4.b.? Y/N NOTE: USCIS may reject or deny your application if DOS initially acted before [Date TBD] to schedule you for an immigrant visa interview.
Pages 4-5, Part 4. Information About Your Qualifying Relative	[Page 4] 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 Your Other Qualifying Relative 3. Do you have more than one qualifying relative (U.S. citizen spouse or parent)? 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 5] 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. U.S. Citizen Spouse 5.b. U.S. Citizen Parent	[Page 4] Part 4. Information About Your Qualifying Relative Provide the following information about the qualifying relative (the U.S. citizen or Lawful Permanent Resident (LPR) spouse or parent) who would experience extreme hardship if you were refused admission to the United States. [no change] 2.a. U.S. Citizen Spouse 2.b. U.S. Citizen Parent 2.c. LPR Spouse 2.d. LPR Parent Your Other Qualifying Relative 3. Do you have more than one qualifying relative (U.S. citizen or LPR spouse or parent)? 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.d. Also provide evidence of the U.S. citizenship or LPR status of the other qualifying relative with your application. See the What Evidence Should I Submit With Form I-601A section of the Instructions. [Page 5] [no change] 5.a. U.S. Citizen Spouse 5.b. U.S. Citizen Parent 5.c. LPR Spouse 5.d. LPR Parent
Page 5, Part 5. Statement from Applicant	[Page 5] 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.	[Page 5] 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. Provide 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 the space provided in Part 9. Additional Information.
Page 6, Part 6. Applicant’s Statement, Contact Information, Acknowledgement of Appointment at USCIS Application Support Center, Certification, and Signature	[Page 6] Part 6. Applicant’s Statement, Contact Information, 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-601A Instructions before completing this part. You must file Form I-601A while in the United States. Applicant's Statement [subheader] 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 the Acknowledgement of Appointment at USCIS Application Support Center. 1.b. 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 [Fillable Field], 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 [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. 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, [Applicant Name], 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 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)	[Page 6] Part 6. Applicant’s Statement, Contact Information, Acknowledgement of Appointment at USCIS Application Support Center, Certification, and Signature [no change] [no change] [no change] [no change] [no change] 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 of U.S. immigration laws. I certify, under penalty of perjury, that the information in my application, my responses to each question, and any document submitted with my application were provided by me and are complete, true, and correct. [no change] NOTE TO 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.
Page 7, Part 7. Interpreter’s Contact Information, Certification, and Signature	[Page 6] Part 7. 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) [Page 7] 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 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 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. 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 6] Part 7. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter. [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change] [no change]
Pages 7-9, Part 8. Contact Information, Statement, Certification, and Signature of the Person Preparing the Application, If Other Than the Applicant	[Page 7] Part 8. Contact Information, Declaration, 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 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 [Page 8] Preparer’s Contact Information 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number (if any) 6. Preparer’s Email Address (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 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)	[Page 7] Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant Provide the following information about the preparer. [no change] [no change] [no change] [no change] 5. Preparer’s Fax Number [no change] [no change] [no change] [no change] [no change] 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. [no change]
Page 9, Part 9. Additional Information	[Page 9] 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. 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]	[Page 9] 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; type or print the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. [no change] [no change] [no change] [no change] [no change] [no change] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Narrative space]

1