Table of Changes (form)

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0123

01/30/2018

Reason for Revision: Extension with Standard Language updates to Signature sections.

• Black font = Current text

• Purple font = Standard language

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
Page 6, Part 6. Applicant’s Statement, Contact Information, Certification, and Signature	[Page 6] Part 6. Applicant’s Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-601A Instructions before completing this part. You must file Form I-601A while in the United States. Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. 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 7. 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 all of this information as interpreted. 2. At my request, the preparer named in Part 8., [Fillable Field], 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. [Page 7] I understand that USCIS will require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, 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.a. Applicant’s Signature 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.	[Page 6] Part 6. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-601A Instructions before completing this section. You must file Form I-601A while in the United States. Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. 1.a. 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 7. 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. At my request, the preparer named in Part 8., [Fillable Field], 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 Declaration and 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. [Page 7] I understand that USCIS will require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, 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 [Delete] 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. Applicant’s Signature 6.a. Applicant’s Signature 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.
Page 7, Part 7. Interpreter’s Contact Information, Certification, and Signature	[Page 7] Part 7. Interpreter’s Contact Information, Certification, and Signature Provide the following information about 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) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 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 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 [Fillable Field], which is the same language specified in Part 6., 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 Certification, and has verified the accuracy of every answer. Interpreter’s Signature 7.a. Interpreter’s Signature 7.b. Date of Signature (mm/dd/yyyy)	[Page 7] Part 7. Interpreter’s Contact Information, Certification, and Signature Provide the following information about 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) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 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 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 [Fillable Field], which is the same language specified in Part 6., 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. Interpreter’s Signature 7.a. Interpreter’s Signature 7.b. Date of Signature (mm/dd/yyyy)
Page 8, Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 8] 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. 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 Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. 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) Preparer’s Statement 7.a. I am not an attorney or accredited representative but have prepared this form on behalf of the authorized individual and with the authorized individual’s consent. 7.b. I am an attorney or accredited representative and have prepared this form on behalf of the authorized individual and with the authorized individual’s consent. 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, 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.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy)	[Page 8] 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. 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 Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. 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) 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, you may need to 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 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. Preparer’s Signature 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy)

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