Form I-601 Application for Waiver of Grounds of Inadmissibility

Application for Waiver of Grounds of Inadmissibility
Department of Homeland Security
U.S. Citizenship and Immigration Services
Initial
Receipt

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Resubmitted

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Relocated
Received
Sent

Benefits Category
Immigrant

USCIS
Form I-601

Adjustment of Status

TPS

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V Nonimmigrant

K Nonimmigrant

Inadmissible Under
212(a)(1)

212(a)(3)

212(a)(6)

212(a)(10)

212(a)(2)

212(a)(4)

212(a)(9)

Other

To be completed
by an Attorney
or Accredited
Representative (if any).

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

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

Mailing Address

1.

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

NOTE: If you are outside of the United States, provide a U.S.
mailing address if available. If a U.S. mailing address is not
available, provide your mailing address outside the United States.

USCIS Online Account Number (if any)
►

5.a. In Care Of Name

2.

Your Full Name

5.b. Street Number
and Name

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

5.c.

3.c. Middle Name

5.e. State

Other Names Used

Apt.

Ste.

Flr.

5.d. City or Town

5.f.

ZIP Code

5.g. Province

List all other names you have ever used, including maiden names,
aliases, and nicknames. If you need extra space to complete this
section, use the space provided in Part 10. Additional
Information.

5.h. Postal Code
5.i.

Country

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

6.

Is your current physical address the same as your mailing
address?
Yes
No

4.c. Middle Name

Form I-601 05/22/15 N

If you answered "No" to Item Number 6., provide your
physical address in Item Numbers 7.a. - 7.h.

Page 1 of 12

Physical Address

16.a. Are you filing this application after you have already filed
Form I-485, Application to Register Permanent Residence
or Adjust Status?
Yes
No

7.a. Street Number
and Name

16.b. If you answered "Yes" to Item Number 16.a., provide
the USCIS Receipt Number for your Form I-485.

Part 1. Information About You (continued)

7.b.

Apt.

Ste.

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

►

Flr.

7.e. ZIP Code

17.a. Are you filing this application after you have already filed
Form I-821, Application for Temporary Protected Status?
Yes
No
17.b. If you answered "Yes" to Item Number 17.a., provide
the USCIS Receipt Number for your Form I-821, if any.

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Province

►

7.g. Postal Code

18.a. Have you previously filed Form I-212, Application for
Permission to Reapply for Admission into the United
States After Deportation or Removal?
Yes
No

7.h. Country

18.b. If you answered "Yes" to Item Number 18.a., provide
the USCIS Receipt Number for your Form I-212, if any.

Other Information
8.

9.
10.
11.

12.

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

Male

►

18.c. Where did you file your application (for example, USCIS
Office, U.S. Port-of-Entry, Immigration Court)?

Female

Date of Birth (mm/dd/yyyy)
City or Town of Birth

18.d. Date Filed (mm/dd/yyyy)
19.

Are you submitting Form I-212 along with this application?
Yes
No

Province of Birth (if applicable)

Part 2. U.S. Entry Information

13.

14.

Country of Birth

Country of Citizenship or Nationality

Provide information for your previous periods of stay in the
United States, beginning with your most recent arrival date.
NOTE: If you need extra space to complete this section, use
the space provided in Part 10. Additional Information.
1.a. Date You Entered the U.S. (mm/dd/yyyy)

If you seek a visa and you were already interviewed by a U.S.
Department of State (DOS) consular officer at a U.S. Embassy
or U.S. Consulate, provide the information requested in Item
Numbers 15.a. - 15.b.
15.a. DOS Consular Case Number (if available)

15.b. The location of the U.S. Embassy or U.S. Consulate where
your visa application is being or will be made

1.b. Immigration Status At the Time of Your Entry Into the U.S.

1.c. Location at Which You Entered the U.S.

1.d. U.S. City or Town Where You Lived

City

Country

Form I-601 05/22/15 N

2.a. Date You Entered the U.S. (mm/dd/yyyy)

Page 2 of 12

Part 2. U.S. Entry Information (continued)
2.b. Date You Departed the U.S. (mm/dd/yyyy)

2.c. Immigration Status At the Time of Your Reentry Into the U.S.

2.d

Location at Which You Entered the U.S.

If you are seeking a waiver of inadmissibility because you have
a Class A Tuberculosis condition (as defined by U.S.
Department of Health and Human Services (HHS) regulations),
you must complete Part 11. of this application.
If you are seeking a waiver of inadmissibility because you have
a history of physical or mental disorders, you must attach the
information requested in the instructions.

Section A

Part 3. Biographic Information (for USCIS
Applicant only)

I am an applicant for an immigrant visa or adjustment of
status (other than based on T nonimmigrant status or based
on classification as a Special Immigrant Juvenile, see Section
B below), or for K or V nonimmigrant status, and I believe
or I was told that I am inadmissible because (review Form
I-601 Instructions for a detailed explanation of the individual
grounds of inadmissibility listed below):

1.

Select all grounds that you believe apply to you.

2.e. U.S. City or Town Where You Lived

2.

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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.

6.

Height

Feet

Weight

Pounds

1.

I have a communicable disease of public health
significance. (A list of communicable diseases of
public health significance can be found in the Specific
Instructions section of Form I-601 Instructions.)

2.

I seek an exemption from the vaccination requirement
because vaccinations are against my religious beliefs
or moral convictions.

3.

I have or had a physical or mental disorder and
behavior (or history of behavior that is likely to recur)
associated with the disorder, which has posed or may
pose a threat to the property, safety, or welfare of
myself or others.

4.

I have been involved in a crime of moral turpitude
(other than a purely political offense).

5.

I have been involved in a controlled substance
violation according to the laws and regulations of any
state, the United States, or a foreign country related
to a single offense of simple possession of 30 grams
or less of marijuana.

6.

I have been convicted of two or more offenses (other
than purely political offenses), for which the combined
sentences to confinement were five years or more.

7.

I am coming to the U.S. to engage in prostitution or,
in the past 10 years, I have engaged in prostitution
(including receiving the proceeds of, in full or in
part), procurement of prostitution, or I continue to
engage in prostitution or procurement of prostitution.

8.

In the past 10 years, I have (either directly or
indirectly) procured, attempted to procure, or to
import prostitutes or persons for the purpose of
prostitution.

Inches

Eye Color (Select only one box)
Black

Blue

Brown

Gray

Green

Maroon

Pink

Hazel
Unknown/Other

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

Black
Gray
White

Blond
Red
Unknown/
Other

Part 4. Reasons for Inadmissibility
Select all of the following grounds that you believe, according to
the best of your knowledge, or that you were told, apply to you.
Only select the applicable grounds listed under the immigration
benefit you are seeking.
If you were ever arrested or convicted, provide the disposition
(outcome) for all arrests or convictions (for example, dismissed
from the appropriate authority). You also will be required to
provide certified court records or dispositions for all convictions.
Form I-601 05/22/15 N

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Part 4. Reasons for Inadmissibility (continued)

Section B

9.

I came to the United States or I am coming to the
United States to engage in any other unlawful
commercialized vice whether or not it is related to
prostitution.

I am applying for adjustment of status based on a valid T
nonimmigrant status or based on classification as a Special
Immigrant Juvenile and I believe or I was told that I am
inadmissible because:

10.

I have been involved in serious criminal activity and
have asserted immunity from prosecution.

19.

11.

I am or I have been a member of or affiliated with the
Communist or any other totalitarian party (or
subdivision or affiliate of the party,) domestic or
foreign.

12.

13.
14.

15.

16.

17.

18.

Specify (Review Form I-601 Instructions for a
detailed explanation of the individual grounds of
inadmissibility related to your Form I-601.)

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I have sought to procure an immigration benefit by
fraud or by concealing or misrepresenting a material
fact (immigration fraud or misrepresentation.)
I have been engaged in alien smuggling.

I am subject to a civil penalty because I was the
subject of a final order for violation of the
Immigration and Nationality Act (INA) section 274C.
I am subject to the 3-year or the 10-year bar to
admissibility because I was previously unlawfully
present in the United States in excess of either 180
days or one year or more, respectively, and
subsequently departed the United States.

I was previously removed from the United States.
(See instructions for Nicaraguan Adjustment and
Central American Relief Act (NACARA) and Haitian
Refugee Immigration Fairness Act (HRIFA) applicants
only. All other applicants file Form I-212.)
I have been ordered removed or I have been
unlawfully present in the United States for more than
one year, in the aggregate, and I subsequently
reentered or attempted to reenter without being
admitted. (See instructions for NACARA, HRIFA,
and the instructions for approved Violence Against
Women Act (VAWA) self-petitioners only. Other
applicants file Form I-212.)

Section C

I am applying for TPS and I believe or I was told that I am
inadmissible because:
Select all grounds that you believe, according to the best of your
knowledge, or that you were told apply to you.

20.

I have a communicable disease of public health
significance. (A list of communicable diseases of
public health significance can be found in the Specific
Instructions section of Form I-601 Instructions.)

21.

I have or had a physical or mental disorder and
behavior (or a history of behavior that is likely to
recur) associated with the disorder, which has posed or
may pose a threat to the property, safety, or welfare of
myself or others.

22.

I am or have been a drug abuser or drug addict as
described in U.S. Department of Health and Human
Services (HHS) Regulations. See 42 CFR 34.

23.

I have been involved in a controlled substance
violation according to the laws and regulations of any
state, the United States, or a foreign country related
to a single offense of simple possession of 30 grams
or less of marijuana.

24.

I am coming to the U.S. to engage in prostitution or,
in the past 10 years, I have engaged in prostitution
(including receiving the proceeds of, in full or in
part,) procurement of prostitution, or I continue to
engage in prostitution or procurement of prostitution.

25.

In the past 10 years, I have (either directly or indirectly,)
procured, attempted to procure, or to import prostitutes
or persons for the purpose of prostitution.

26.

I came to the United States or I am coming to the
United States to engage in any other unlawful
commercialized vice, whether or not it is related to
prostitution.

27.

I have been involved in serious criminal activity and
have asserted immunity from prosecution.

28.

I did not attend or did not remain at a removal
proceeding to determine my inadmissibility or
deportability.

Other (specify):

Form I-601 05/22/15 N

Page 4 of 12

Part 4. Reasons for Inadmissibility (continued)
29.

I have sought to procure an immigration benefit by
fraud or by concealing or misrepresenting a material
fact (immigration fraud or misrepresentation).

30.

I falsely represented myself as a U.S. citizen.

31.

I have been engaged in alien smuggling.

32.

I am subject to a civil penalty because I have been the
subject of a final order for violation of INA section
274C.

33.

I am ineligible for U.S. citizenship because I departed
from or remained outside the United States to avoid
or evade training or service in the armed forces in a
time of war or national emergency.

34.

35.

36.

37.

38.

39.

40.

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I have practiced polygamy since I entered the United
States or I intend to practice polygamy in the United
States.

I am accompanying another alien who is inadmissible
after being certified to be helpless under INA section
232(c) and I am inadmissible because that other alien
requires my protection or guardianship.

I have detained, retained, or withheld the custody of a
child having a lawful claim to U.S. citizenship, outside
the United States, from a person granted custody.

I was an unlawful voter who voted in violation of a
Federal, state, or local constitutional provision, statute,
ordinance, or regulation.

I am a former U.S. citizen who renounced my
citizenship in order to avoid taxation by the United
States.
Other (specify):

Your Inadmissibility Statement
In the space provided in Item Number 40., provide a statement
and a full explanation of the acts, convictions, and/or medical
conditions that you believe or you were told make you
inadmissible.
Your statement must indicate when you engaged in the acts that
you believe make you inadmissible, the date of all convictions,
or the date of any medical diagnosis. You must provide this
information even if the information is also in the documents that
you submit with your application.
If you need extra space to complete your statement, use the
space provided in Part 10. Additional Information or attach a
separate letter. If you include a separate letter, indicate in Item
Number 39. that you are attaching a letter.

Form I-601 05/22/15 N

Page 5 of 12

Part 5. Information About Your Qualifying
Relatives
Provide information for your U.S. citizen or lawful permanent
resident through whom you are eligible to submit this
application. In Item Number 9., provide a statement
explaining the extreme hardship that you or your qualifying
relative (U.S. citizen, lawful permanent resident, or other
qualified parent or child) has or will experience if you are
refused the immigration benefit you are seeking. It is not
necessary for an SIJ to complete Part 5. of the application.
Select here if you are a VAWA self-petitioner and would
like to claim extreme hardship to yourself. (If you are only
claiming extreme hardship for yourself, you can skip to Item
Number 9. If you have additional qualifying relatives to
whom you would like to claim extreme hardship, provide
their information below.)

5.

What is your relative's relationship to you?

6.

What is your relative's immigration status?

7.

Relative's A-Number (if any)
► A-

8.

Date of Birth (mm/dd/yyyy)

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In the space provided below, explain the extreme hardship that
your qualifying relative (or yourself if you are a VAWA selfpetitioner) would experience if you are refused the immigration
benefit you are seeking. For more information on extreme
hardship, see Form I-601 Instructions. If you need extra space
to complete your statement, use the space provided in Part 10.
Additional Information or attach a separate letter. Indicate in
Item Number 9. if you are attaching a separate letter. The
letter must be submitted at the same time as your Form I-601
application.

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

1.c. Middle Name

Physical Address
2.a. Street Number
and Name
Apt.

Select this box if you have additional relatives through
whom you claim eligibility and use the space provided in
Part 10. Additional Information to provide the same
information as requested in Part 5., Item Numbers 1.a. - 8.

Statement From Applicant (Extreme Hardship)

Relative's Full Name

2.b.

Other Information

Ste.

Flr.

9.

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

2.e. ZIP Code

Province

2.g. Postal Code
2.h. Country

Contact Information
3.

Daytime Telephone Number (if any)

4.

Email Address (if any)

Part 6. Information About Your Other Relatives
With Ties to the United States
Provide information for any other U.S. citizen, lawful permanent
resident, or any other family members you would like considered
in deciding your case. In the space provided in Item Number 9.,
include a statement explaining why you believe your application
should be approved as a matter of discretion, with the favorable
factors outweighing the unfavorable factors in your case.

Relative's Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

Form I-601 05/22/15 N

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Part 6. Information About Your Other Relatives
With Ties to the United States (continued)
Physical Address
2.a. Street Number
and Name
2.b.

Apt.

Ste.

Flr.

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

2.e. ZIP Code

Statement From Applicant (Discretion)
In the space provided below, explain why you believe your
application should be approved as a matter of discretion, with
the favorable outweighing the unfavorable factors in your case.
For more information on discretion, see Form I-601 Instructions.
If you need extra space to complete your statement, use the
space provided in Part 10. Additional Information or attach a
separate letter. Indicate in Item Number 9. if you are attaching
a separate letter. The letter must be submitted at the same time
as your Form I-601 application.
9.

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Province

2.g. Postal Code
2.h. Country

Contact Information
3.

4.

Daytime Telephone Number (if any)

Email Address (if any)

Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

Read the Penalties section of the Form I-601 Instructions
before completing this part. You must file Form I-601 while in
the United States.

Other Information

Applicant's Statement

5.

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

6.

7.

8.

What is your relative's relationship to you?

What is your relative's immigration status?

Relative's A-Number (if any)
► A-

1.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.

1.b.

The interpreter named in Part 8. read to me every
question and instruction on this application and my
answer to every question, in

Date of Birth (mm/dd/yyyy)
Select this box if you have any other relatives with ties to
the United States and use the space provided in Part 10.
Additional Information to provide the same information
as requested in Part 6., Item Numbers 1.a. - 8.

,
a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer named in Part 9.,

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

Form I-601 05/22/15 N

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Part 8. Interpreter's Contact Information,
Certification, and Signature

Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)

Provide the following information about the interpreter.

Applicant's Contact Information

Interpreter's Full Name

3.

Applicant's Daytime Telephone Number

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

4.

Applicant's Mobile Telephone Number (if any)

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

5.

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Applicant's Email Address (if any)

2.

Interpreter's Business or Organization Name (if any)

Applicant's Certification

Interpreter's Mailing Address

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.

3.a. Street Number
and Name

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 law.
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 understood all of the information
contained in, and submitted with, my application; and

2) All of this information was complete, true, and correct
at the time of filing.

I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.

3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. 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

Applicant's Signature

I certify, under penalty of perjury, that:

6.a. Applicant's Signature

I am fluent in English and

6.b. 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 may deny your application.
Form I-601 05/22/15 N

,

which is the same language specified in Part 7., Item Number
1.b., 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 Declaration and
Certification, and has verified the accuracy of every answer.
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Part 8. Interpreter's Contact Information,
Certification, and Signature (continued)

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.

Interpreter's Signature
7.a. Interpreter's Signature

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

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant

NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, or G-28I,
Notice of Entry of Appearance as Attorney in Matters
Outside the Geographical Confines of the United
States, with this application.

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Provide the following information about the preparer.

Preparer's Full Name

Preparer's Certification

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

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 Declaration and 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.

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

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

8.a. Preparer's Signature

Ste.

Flr.

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

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

Preparer's Signature

3.e. ZIP Code

Province

3.g. Postal Code
3.h. 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)

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Page 9 of 12

5.a. Page Number

Part 10. 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.

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.b. Part Number

3.c. Item Number

6.a. Page Number

3.d.

6.b. Part Number

6.c. Item Number

6.d.

4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.

Form I-601 05/22/15 N

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Part 11. Statement for Applicants With a Class
A Tuberculosis Condition (As Defined By HHS
Regulations)
To be completed for applicants with a Class A Tuberculosis
Condition (as defined by HHS Regulations).

Physical Address
4.a. Street Number
and Name
4.b.

Apt.

Ste.

Flr.

4.c. City or Town

Statement by Applicant
Upon admission to the United States, I will go directly to the
health department named in the section below; present all X-rays
used in the visa medical examination to substantiate diagnosis;
submit to such examinations, treatment, isolation, and medical
regimen as may be required; and remain under the prescribed
treatment or observation, whether on an inpatient or outpatient
basis, until discharged.

4.d. State

4.e. ZIP Code

Physician's Certification

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1.a. Signature of Applicant

5.a. Signature of Physician

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

5.c. Physician's Family Name (Last Name)

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

5.d. Physician's Given Name (First Name)

Statement by Local (City or County) Health
Department

Physician's Contact Information

NOTE: The physician at the local health department in the area
where the alien plans to reside should complete this statement.

6.

Daytime Telephone Number

I agree to supply any treatment or observation necessary for the
proper management and continued care of the alien's
tuberculosis condition.

7.

Email Address (if any)

Within 30 days of the alien reporting for care, I agree to submit
a summary of my initial evaluation of the alien's condition,
indicate presumptive diagnosis, and provide test results and
plans for future care of the alien to the State Health Department
Official named in the Endorsement of State Health
Department Official section and to the Division of Global
Migration and Quarantine (E03), Centers for Disease
Control and Prevention (CDC), Atlanta, Georgia 30333.
I also agree to report the alien if the alien has not reported
within 30 days after receiving notice from the Division of
Global Migration and Quarantine, CDC.

Satisfactory financial arrangements have been made. (This
statement does not relieve the alien from submitting evidence,
as required by a U.S. Consulate, to establish that the alien is not
likely to become a public charge.)
I represent (select the appropriate box and give the complete
name, address, certification, and contact information of the
health department):
2.a.

City Health Department

2.b.

County Health Department

3.

Arrangement for Medical Care by the Applicant or
His or Her Sponsor

Arrange for medical care (of the applicant) and have the
appropriate health departments complete Statement by Local
(City or County) Health Department and Endorsement of
State Health Department Official sections.
Provide the following information:
Address where you (the sponsor) or the applicant plan to reside
in the United States:
8.a. Street Number
and Name
8.b.

Apt.

Ste.

Flr.

8.c. City or Town
8.d. State

8.e. ZIP Code

Name of Health Department

Form I-601 05/22/15 N

Page 11 of 12

Part 11. Statement for Applicants With a Class
A Tuberculosis Condition (As Defined By HHS
Regulations) (continued)
Endorsement of State Health Department Official

NOTE to the Applicant: If you are approved for a waiver and
after admission to the United States, you fail to comply with the
terms, conditions, and controls that were imposed with the grant
of the waiver, you may be subject to removal under INA
section 237(a).

NOTE: The State Health Department Official in the area
where the applicant plans to reside should complete this
statement.
Endorsement signifies recognition of the local health
department that completed the Statement by Local (City or
County) Health Department section for the purpose of
providing care and treatment of the applicant's tuberculosis
condition, and that the local health department is within your
jurisdiction. Endorsement also signifies recognition that the
applicant will be residing within your state's health jurisdiction.

DRAFT
NOT FOR
PRODUCTION
01/03/2017

Endorsed by:

9.a. Signature of State Health Department Official

9.b. Date of Signature (mm/dd/yyyy)
10.

Name of State Health Department

Physical Address
11.a. Street Number
and Name
11.b.

Apt.

Ste.

Flr.

11.c. City or Town
11.d. State

11.e. ZIP Code

Contact Information
12.

Daytime Telephone Number

13.

Email Address (if any)

NOTE to the Applicant and his or her Sponsor: If you need
assistance, contact USCIS at the National Customer Service
Center at 1-800-375-5283. You may also schedule an
appointment online at www.uscis.gov. Select "Schedule an
Appointment" and follow the screen prompts to set up your
appointment. Once you finish scheduling an appointment, the
system will generate an appointment notice for you.

Form I-601 05/22/15 N

Page 12 of 12