Form I-191 Application for Relief under Former Section 212(c) of th

Application for Relief Under Former Section 212(c)
of the Immigration and Nationality Act (INA)
Department of Homeland Security
U.S. Citizenship and Immigration Services

Draft
Fee Stamp

Date (mm/dd/yyyy)

USCIS
Form I-191
OMB No. 1615-0016
Expires 08/31/2016

Action Block

For
USCIS
Use
Only
RECEIVED

TRANS IN

RETD/TRANS OUT

COMPLETED

Not for

Select this box if
Form G-28 or
Form G-28I is
attached.

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

Attorney State Bar Number
(if applicable)

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

► START HERE - Type or print in black ink.

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.

Reproduction

Your Full Name (do not provide a nickname)
Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

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)

3.

Given Name (First Name)

Middle Name

07/12/2016

Date of Birth (mm/dd/yyyy)

4.

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

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

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Part 1. Information About You (continued)
8.

Draft

Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

9.

Postal Code

Physical Address
Street Number and Name

ZIP Code

Country

Not for

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Reproduction

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

07/12/2016

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)

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Part 1. Information About You (continued)

Draft

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

Not for
Returned To The United States

Place or Port-of-Entry

Date of Entry
(mm/dd/yyyy)

Means of Transportation

Purpose of Trip(s)

Reproduction
07/12/2016

Form I-191 08/15/13 Y

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Part 2. Biographic Information
1.

Hispanic or Latino
2.

Not Hispanic or Latino

Race (Select all applicable boxes)
Asian

White

Black or African
American

3.

Height

Feet

4.

Weight

Pounds

5.

Eye Color (Select only one box)
Black

6.

Draft

Ethnicity (Select only one box)

American Indian or
Alaska Native

Native Hawaiian or
Other Pacific Islander

Inches

Blue

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

Black

Not for

Brown

Gray

Blond

Brown

Green

Hazel

Gray

Maroon

Red

Pink

Sandy

White

Unknown/Other

Unknown/
Other

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.

Reproduction

Criminal Conviction 1

A. Date (mm/dd/yyyy)

B. Name of Court

C. Location of Court
Town or City

State

D. Court Case Number

07/12/2016

E. Conviction Entered

After Trial

Based on Guilty or No Contest Plea

If based on 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

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Part 3. Information About Your Criminal Convictions (continued)
2.

Draft

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

Not for

After Trial

Based on Guilty or No Contest Plea

If based on 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.)

Reproduction

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

07/12/2016

D. Court Case Number
E. Conviction Entered

After Trial

Based on Guilty or No Contest Plea

If based on 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.

Form I-191 08/15/13 Y

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Part 4. Information About Your Residence

Draft

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.
1.

Physical Address 1
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Not for

Province

Postal Code

Date of Residence
2.

To (mm/dd/yyyy)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Reproduction

Date of Residence

Postal Code

From (mm/dd/yyyy)

Country

To (mm/dd/yyyy)

Physical Address 3
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Date of Residence
4.

From (mm/dd/yyyy)

Country

Physical Address 2

Province

3.

ZIP Code

ZIP Code

07/12/2016
Postal Code

From (mm/dd/yyyy)

Country

To (mm/dd/yyyy)

Physical Address 4
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Date of Residence

Form I-191 08/15/13 Y

Postal Code

From (mm/dd/yyyy)

ZIP Code

Country

To (mm/dd/yyyy)

Page 6 of 17

Part 4. Information About Your Residence (continued)
5.

Physical Address 5
Street Number and Name

Draft

City or Town

State

Province

Postal Code

Date of Residence

Apt. Ste. Flr. Number

ZIP Code

Country

Not for

From (mm/dd/yyyy)

To (mm/dd/yyyy)

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

Reproduction

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Date

From (mm/dd/yyyy)

Your Occupation
2.

Postal Code

Employer 2
Name of Employer

ZIP Code

Country

To (mm/dd/yyyy)

07/12/2016

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Date

From (mm/dd/yyyy)

Postal Code

ZIP Code

Country

To (mm/dd/yyyy)

Your Occupation

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Part 5. Information About Your Employment (continued)
3.

Draft

Employer 3
Name of Employer

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Date

Not for
Postal Code

From (mm/dd/yyyy)

Your Occupation

ZIP Code

Country

To (mm/dd/yyyy)

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.

Reproduction

A. Information About Your Spouse
Spouse's Current Legal Name
Family Name (Last Name)

Given Name (First Name)

Spouse's Country of Birth

Middle Name

Spouse's Date of Birth (mm/dd/yyyy)

Spouse's Country of Citizenship or Nationality

07/12/2016

Spouse's Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-191 08/15/13 Y

Postal Code

ZIP Code

Country

Page 8 of 17

Part 6. Information About Your Family (continued)
B. Information About Your Children

Draft

Provide the following information about all of your children.
Child 1
Current Legal Name
Family Name (Last Name)

Given Name (First Name)

Middle Name

Date of Birth (mm/dd/yyyy)

Country of Birth

Not for

Country of Citizenship or Nationality

Current Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Child 2

Postal Code

ZIP Code

Country

Reproduction

Current Legal Name

Family Name (Last Name)

Given Name (First Name)

Middle Name

Date of Birth (mm/dd/yyyy)

Country of Birth

07/12/2016

Country of Citizenship or Nationality

Current Address

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-191 08/15/13 Y

Postal Code

ZIP Code

Country

Page 9 of 17

Part 6. Information About Your Family (continued)

Draft

Child 3
Current Legal Name
Family Name (Last Name)

Given Name (First Name)

Middle Name

Date of Birth (mm/dd/yyyy)

Country of Birth

Country of Citizenship or Nationality

Current Address
Street Number and Name

Not for

Apt. Ste. Flr. Number

City or Town

State

Province

Child 4

Postal Code

ZIP Code

Country

Reproduction

Current Legal Name

Family Name (Last Name)

Given Name (First Name)

Middle Name

Date of Birth (mm/dd/yyyy)

Country of Birth

Country of Citizenship or Nationality

Current Address

07/12/2016

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-191 08/15/13 Y

Postal Code

ZIP Code

Country

Page 10 of 17

Part 6. Information About Your Family (continued)
C. Information About Your Parents
Parent 1
Parent 1's Current Legal Name
Family Name (Last Name)

Sex

Male

Female

Parent 1's Country of Birth

Parent 1's Physical Address
Street Number and Name

Draft
Given Name (First Name)

Parent 1's Date of Birth (mm/dd/yyyy)
Parent 1's Country of Citizenship or Nationality

Not for

Apt. Ste. Flr. Number

City or Town

State

Province

Parent 2

Middle Name

Postal Code

ZIP Code

Country

Reproduction

Parent 2's Current Legal Name
Family Name (Last Name)

Sex

Male

Female

Given Name (First Name)

Middle Name

Parent 2's Date of Birth (mm/dd/yyyy)
Parent 2's Country of Citizenship or Nationality

Parent 2's Country of Birth

07/12/2016

Parent 2's Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-191 08/15/13 Y

Postal Code

ZIP Code

Country

Page 11 of 17

Part 7. Other Grounds for Removal

Draft

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).

Not for

If you need extra space to complete your statement, use the space provided in Part 12. Additional Information or attach a separate
letter.

Reproduction
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.

07/12/2016

Form I-191 08/15/13 Y

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Part 9. Applicant's Statement, Contact Information, Certification, and Signature

Draft

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

Not for

, 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.,

,

prepared this application for me based only upon information I provided or authorized.

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)

Reproduction

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.

07/12/2016

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.

Form I-191 08/15/13 Y

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Part 10. Interpreter's Contact Information, Certification, and Signature

Draft

Provide the following information about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.

Street Number and Name

City or Town

Interpreter's Given Name (First Name)

Not for

Apt. Ste. Flr. Number

State

Province

ZIP Code

Country

Postal Code

Interpreter's Contact Information

Reproduction

4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification
I certify, under penalty of perjury, that:
, which is the same language specified in Part 9.,
I am fluent in English and
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.

07/12/2016

Interpreter's Signature
7.

Interpreter's Signature

Form I-191 08/15/13 Y

Date of Signature (mm/dd/yyyy)

Page 14 of 17

Part 11. Contact Information, Declaration, and Signature of the Person Preparing This Application, if
Other Than the Applicant

Draft

Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Preparer's Given Name (First Name)

Not for

Apt. Ste. Flr. Number

State

City or Town

Province

Postal Code

ZIP Code

Country

Reproduction

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone 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.

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.

07/12/2016

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

Form I-191 08/15/13 Y

Date of Signature (mm/dd/yyyy)

Page 15 of 17

Part 12. Additional Information

Draft

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)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

A. Page Number

D.

5.

Given Name (First Name)

Middle Name

Not for

B. Part Number

B. Part Number

C. Item Number

C. Item Number

Reproduction

A. Page Number

B. Part Number

C. Item Number

D.

07/12/2016
6.

A. Page Number

B. Part Number

C. Item Number

D.

Form I-191 08/15/13 Y

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For USCIS Use Only

Draft

Decision

Application granted upon the following terms and conditions:

Not for
Date of Action (mm/dd/yyyy)

Reproduction
07/12/2016

Form I-191 08/15/13 Y

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