Form I-191 Table of Changes

TABLE OF CHANGES – FORM

Form I-191, Application for Relief under Former Section 212(c) of the Immigration and Nationality Act

OMB Number: 1615-0016

07/12/2016

Reason for Revision: Update USCIS Online data collection reference, standard language, revised signature sections, and standard formatting.

Current Page Number and Section	Current Text	Proposed Text
Page 1	Action Block Fee Stamp Date RECEIVED TRANS In RET’D-TRANS. OUT COMPLETED Remarks	[Page 1] For USCIS Use Only [No change] [No change] Date (mm/dd/yyyy) RECEIVED TRANS IN RET’D/TRANS OUT COMPLETED [Delete]
NEW		[Page 1] To be completed by an attorney or accredited representative (if any). [] Select this box if Form G-28 or Form G-28I is attached Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)
NEW		[Page 1] START HERE – Type or print in black ink.
Page 1	(1) I hereby apply for permission to return to the United States under the authority contained in Section 212 (c) of the Immigration and Nationality Act. MY NAME IS: (First) (Middle) (Last) DATE OF BIRTH: (mm/dd/yyyy) PLACE OF BIRTH: (City, Province, Country) I AM A CITIZEN/NATIONAL OF: (Country) PRESENT ADDRESS: (Street and number, apt no., city, state, country) (2) I was lawfully admitted to the United State for permanent residence at: PORT OF ENTRY/DHS OFFICE: DATE: (mm/dd/yyyy) NAME OF VESSEL OR OTHER MEANS OF CONVEYANCE: (3) Since that admission, I have departed from and reentered the United States as follows: DEPARTED FROM THE UNITED STATES Port Date (mm/dd/yyyy) Vessel or Other Means of Conveyance RETURNED TO THE UNITED STATES Port Date (mm/dd/yyyy) Vessel or Other Means of Conveyance PURPOSE OF TRIP	[Page 1] Part 1. Information About You I am applying for permission to return to the United States under the authority contained in former section 212(c) of the Immigration and Nationality Act (INA). 1. Your Full Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name 2. Other Names Used List all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 12. Additional Information. Family Name (Last Name) Given Name (First Name) Middle Name 3. Date of Birth (mm/dd/yyyy) 4. Alien Registration Number (A-Number) (if any) 5. USCIS Online Account Number (if any) 6. Place of Birth City/Town/Village of Birth State/Province of Birth Country of Birth 7. Country of Citizenship or Nationality 8. Mailing Address In Care Of Name (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 9. Physical Address Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 10. Information About When and How You Became a Lawful Permanent Resident (LPR) A. Date When You Obtained Your LPR status (mm/dd/yyyy) B. You Obtained Your LPR Status Through (select only one) [] Admission With an Immigrant Visa at a Port-of-Entry Port-of-Entry, If Known__________________ Means of Transportation [] Adjustment of Status While in the United States USCIS Office ________________________ 11. Passport Number Used at Last Entry 12. Travel Document Number Used at Last Entry 13. Country of Issuance for Passport or Travel Document 14. Expiration Date of This Passport or Travel Document (mm/dd/yyyy) 15. Information About Your Departures From and Returns To the United States Since being admitted as an LPR, you have departed from and returned to the United States as follows: Departed From The United States Place or Port-of-Departure Date of Departure (mm/dd/yyyy) Means of Transportation Returned To The United States Place or Port-of-Entry Date of Entry (mm/dd/yyyy) Means of Transportation Purpose of Trip(s)
		[Page 4] [NEW] 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] [NEW] Part 3. Information About Your Criminal Convictions The information you provide below relates to the criminal convictions for which you are seeking relief under former section 212(c) of the Immigration and Nationality Act. 1. Criminal Conviction 1 Date (mm/dd/yyyy) Name of Court Location of Court Town or City State Court Case Number Conviction Entered [] After Trial [] Based on Guilty or No Contest Plea If based on a guilty or no contest plea, give the date of the guilty or no contest plea. (mm/dd/yyyy)_________ Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific offense.) Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide each separate citation.) Sentence, Probation, or Other Punishment Imposed 2. Criminal Conviction 2 A. Date (mm/dd/yyyy) B. Name of Court C. Location of Court Town or City State D. Court Case Number E. Conviction Entered [] After Trial [] Based on Guilty or No Contest Plea If based on a guilty or no contest plea, give the date of the guilty or no contest plea. (mm/dd/yyyy)_________ F. Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific offense.) G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide each separate citation.) H. Sentence, Probation, or Other Punishment Imposed 3. Criminal Conviction 3 A. Date (mm/dd/yyyy) B. Name of Court C. Location of Court Town or City State D. Court Case Number E. Conviction Entered [] After Trial [] Based on Guilty or No Contest Plea If based on a guilty or no contest plea, give the date of the guilty or no contest plea. (mm/dd/yyyy)_________ F. Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific offense.) G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide each separate citation.) H. Sentence, Probation, or Other Punishment Imposed NOTE: If you were convicted more than three times, include the information for each additional conviction in Part 12. Additional Information.
Page 1, Number 4.	(4) During the past 7 years I have resided at the following places: (List present address first) (Complete Address – Include Apt No.) From – To- Present Time	[Page 5] Part 4. Information About Your Residence Provide the following information about where you have lived during the last seven years. List your most recent residence first and then every other residence where you have lived during the last seven years. There should be no gaps in time. If you need extra space to complete this section, use the space provided in Part 12. Additional Information. Physical Address 1 Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) PRESENT Physical Address 2 Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Physical Address 3 Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Physical Address 4 Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Physical Address 5 Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy)
Page 1, Number 5.	(5) During the past 7 years I have been employed as follows: (List present employment first)	[Page 7] Part 5. Information About Your Employment Provide the following information about your employment. List where you have worked full-time or part-time during the last seven years. If you need extra space to complete this section, use the space provided in Part 12. Additional Information. 1. Employer 1 Name of Employer Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date From (mm/dd/yyyy) To (mm/dd/yyyy) Present Your Occupation 2. Employer 2 Name of Employer Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date From (mm/dd/yyyy) To (mm/dd/yyyy) Your Occupation 3. Employer 3 Name of Employer Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date From (mm/dd/yyyy) To (mm/dd/yyyy) Your Occupation
Page 1, Number 6	(6) My immediate family (spouse, unmarried minor children and parents) consists of the following persons: Name Relation Date and Country of Birth Citizen of Present Address	[Page 8] Part 6. Information About Your Family Provide the following information about your family (for example, spouse, children, and parents). If you need extra space to complete this section, use the space provided in Part 12. Additional Information. A. Information About Your Spouse Spouse’s Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Spouse’s Country of Birth Spouse’s Date of Birth (mm/dd/yyyy) Spouse’s Country of Citizenship or Nationality Spouse’s Physical Address Street Number and Name Apt. Ste. Flr Number City or Town State ZIP Code Province Postal Code Country B. Information About Your Children Provide the following information about all of your children. Child 1 Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Country of Birth Date of Birth (mm/dd/yyyy) Country of Citizenship or Nationality Current Address Street Number and Name Apt. Ste. Flr Number City or Town State ZIP Code Province Postal Code Country Child 2 Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Country of Birth Date of Birth (mm/dd/yyyy) Country of Citizenship or Nationality Current Address Street Number and Name Apt. Ste. Flr Number City or Town State ZIP Code Province Postal Code Country Child 3 Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Country of Birth Date of Birth (mm/dd/yyyy) Country of Citizenship or Nationality Current Address Street Number and Name Apt. Ste. Flr Number City or Town State ZIP Code Province Postal Code Country Child 4 Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Country of Birth Date of Birth (mm/dd/yyyy) Country of Citizenship or Nationality Current Address Street Number and Name Apt. Ste. Flr Number City or Town State ZIP Code Province Postal Code Country C. Information About Your Parents Parent 1 Parent 1’s Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Sex Male Female Parent 1’s Date of Birth (mm/dd/yyyy) Parent 1’s Country of Birth Parent 1’s Country of Citizenship or Nationality Parent 1’s Physical Address Street Number and Name Apt. Ste. Flr Number City or Town State ZIP Code Province Postal Code Country Parent 2 Parent 2’s Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Sex Male Female Parent 2’s Date of Birth (mm/dd/yyyy) Parent 2’s Country of Birth Parent 2’s Country of Citizenship or Nationality Parent 2’s Physical Address Street Number and Name Apt. Ste. Flr Number City or Town State ZIP Code Province Postal Code Country
	(7) I,_________________________________ departed temporarily from the United States on or about __________ and will remain in ______________ approximately _____________, for the purpose of _______________; and expect to apply for admission at ______________________ (Port) (8) I believe I may be inadmissible to the United States for the following reasons: __________________________________________________________________________________________________________________ I understand that the information herein contained may be used in any criminal or civil proceedings, including removal, hereafter instituted against me. I certify that the statements above are true and correct to the best of my knowledge and belief. (Signature of Applicant)	[Page 12] Part 7. Other Grounds of Removal If you believe you may be subject to removal on any grounds besides the criminal convictions listed in Part 3. Information About Your Criminal Convictions, provide a full explanation of why you may be subject to removal. The other grounds of removal may be any inadmissibility grounds in section 212(a) of the Immigration and Nationality Act or any deportability grounds in section 237(a) of the Immigration and Nationality Act. If you have a criminal history besides the criminal convictions listed in Part 3. Information About Your Criminal Convictions, list these incidents and provide a full explanation. If you have ever been arrested or detained by any law enforcement officer for any reason, and no charges were filed, include an original official statement by the arresting or detaining agency or applicable court order confirming that no charges were filed. If you were arrested or detained by any law enforcement officer for any reason and charges were filed, or if charges were filed against you without an arrest, submit an original or court-certified copy of the complete arrest record and/or disposition for each incident (for example, a dismissal order or an acquittal order). If you need extra space to complete your statement, use the space provided in Part 12. Additional Information or attach a separate letter.
NEW		[Page 12] Part 8. Discretion In the space provided below, explain why you believe your application should be approved as a matter of discretion, with the favorable factors outweighing the unfavorable factors in your case. For more information on discretion, see the application Instructions. If you need extra space to complete your statement, use the space provided in Part 12. Additional Information or attach a separate letter. Indicate in the space provided if you are including a separate letter. If you submit a separate letter, you must submit the letter at the same time as your Form I-191 application.
Page 2,	(8) I believe I may be inadmissible to the United States for the following reasons: I understand that the information herein contained may be used in any criminal or civil proceedings, including removal, hereafter instituted against me. I certify that the statements above are true and correct to the best of my knowledge and belief. Signature of Applicant	[Page 12] Part 9. Applicant’s Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-191 Instructions before completing this part. Applicant’s Statement NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant’s Statement Regarding the Interpreter A. [] I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. B. [] The interpreter named in Part ­10. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent and I understood everything. 2. Applicant’s Statement Regarding the Preparer [] At my request, the preparer named in Part 11., [Fillable Filed], prepared this application for me based only upon information I provided or authorized. 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) 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 of my records that USCIS may need to determine my eligibility for the immigration benefit I seek. I further 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 understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and provided or authorized all of the information in my application; 2) I understood all of the information contained in, and submitted with, my application; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct. Applicant’s Signature 6. Applicant’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, USCIS (or an immigration judge if you are in deportation, exclusion, or removal proceedings) may deny your application.
NEW		[Page 14] Part 10. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter. Interpreter’s Full Name 1. Interpreter’s Family Name (Last Name) Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name (if any) Interpreter’s Mailing Address 3. 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 Mobile Telephone Number (if any) 6. Interpreter’s Email Address (if any) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and ________________, which is the same language specified in Part 9., Item B., in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer. Interpreter’s Signature 7. Interpreter’s Signature Date of Signature (mm/dd/yyyy)
Page 2	Address I declare that the document was prepared by me at the request of the applicant and is based on all information of which I have knowledge. Signature of person preparing form, in other than applicant. Signature Date	[Page 15] Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer’s Full Name 1. Preparer’s Family Name (Last Name) Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) 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 5. Preparer’s Mobile Telephone 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. 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, 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, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant’s Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer’s Signature 8. Preparer’s Signature Date of Signature (mm/dd/yyyy)
NEW		[Page 16] Part 12. 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. Type or print 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. Family Name (Last Name) Given Name (First Name) Middle Name 2. A-Number (if any) [Auto-populated field] 3.A. Page Number B. Part Number C. Item Number D. ___________________________________ 4.A. Page Number B. Part Number C. Item Number D. ___________________________________ 5. A. Page Number B. Part Number C. Item Number D. ___________________________________ 6. A. Page Number B. Part Number C. Item Number D. ________________________________
	Decision: [] Application granted upon the following terms and conditions: DATE OF ACTION DD DISTRICT	[Page 17] For USCIS Use Only Decision [] Application granted upon the following terms and conditions: Date of Action (mm/dd/yyyy) [Delete] [Delete]

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