I-602 Form TOC

TABLE OF CHANGES – FORM

Form I-602, Application by Refugee for Waiver of Inadmissibility Grounds

OMB Number: 1615-0069

09/11/2018

Reason for Revision:

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
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)
Page 1, Part 1.	[Page 1] To be completed by all applicants (Type or print in black ink) PART 1. Family Name (in capital letters) First Name Middle Name Place of Birth (City of Town) Country of Birth Present Address: Number and Street City or Town State ZIP Code A-Number Date of Birth (mm/dd/yyyy) Country of Citizenship	[Page 1] START HERE - Type or print in black ink. Part 1. Information About You Your Full Legal Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Place of Birth 2.a. City or Town of Birth 2.b. State or Province of Birth 2.c. Country of Birth Mailing Address 3.a. In Care Of Name (if any) 3.b. Street Number and Name 3.c. Apt. Ste. Flr. 3.d. City or Town 3.e. State 3.f. ZIP Code 3.g. Province 3.h. Postal Code 3.i. Country 4. Is your current mailing address the same as your physical address? Yes/No If you answered “No” to Item Number 4., provide your physical address in Item Numbers 5.a. - 5.h. [Page 2] Physical Address 5.a. Street Number and Name 5.b. Apt. Ste. Flr. 5.c. City or Town 5.d. State 5.e. ZIP Code 5.f. Province 5.g. Postal Code 5.h. Country Other Information 6. Alien Registration Number (A-Number) (if any) 7. USCIS Online Account Number (if any) 8. Date of Birth (mm/dd/yyyy) 9. Country of Citizenship or Nationality 10. Current Status [] I am a principal refugee applicant currently outside the United States. [] I am a derivative refugee applicant outside the United States. [] I am a derivative refugee applicant inside the United States. [] I am a refugee currently present in the United States seeking adjustment of status. [] I am an asylee currently present in the United States seeking adjustment of status.
Page 1, Part 2.	[Page 1] PART 2. I have been declared inadmissible or ineligible for adjustment of status under the following section(s) of 212(a) of the Immigration and Nationality Act (INA). (NOTE: Sections 212(a)(4), 212(a)(5), and 212(a)(7)(A) do not apply to refugees under Sections 207 or 209 of the INA.) I am inadmissible because: (List the specific acts, convictions, or physical or mental conditions. If you have active or suspected tuberculosis, fully complete Part 3 on Page 2. If you have, or have had, a physical or mental disorder, and behavior associated with the disorder that may pose, or has posed, a threat to the property, safety, or welfare of you or others, complete Part3A on Page 2.) I request a waiver of the grounds inadmissibility listed above for the following reasons: (Check the appropriate block and explain below) [ ] For humanitarian reasons [ ] To assure family unity [ ] In the public interest Applicant’s Signature: Date: Do not write below this line (For USCIS Use Only) [ ] Waiver of grounds of inadmissibility is granted. [ ] Waiver of ground of inadmissibility is denied. Basis for Denial: Date of Action USCIS Office Director USCIS Field Office	[Page 2] Part 2. Reasons for Inadmissibility Select all of the following grounds that you believe apply to you, according to what you were told or to the best of your knowledge. Read the Form I-602 Instructions carefully. If you are seeking a waiver because you are seeking an exemption from the vaccination requirements or because you have a physical or mental disorder with associated harmful behavior, or drug abuse or addiction, you must attach the information requested in the Instructions. NOTE: The Immigration and Nationality Act (INA) sections 212(a)(4), 212(a)(5), and 212(a)(7)(A) do not apply to refugees under INA section 207 or refugees or asylees seeking to adjust their status to lawful permanent resident under INA section 209. I believe or I was told that I am inadmissible because (select all grounds that you believe apply to you): 1. I have a communicable disease of public health significance. See INA section 212(a)(1)(A)(i). (The Form I-602 Instructions has a list of communicable diseases of public health significance.) 2. I seek an exemption from the vaccination requirement because vaccinations are against my religious beliefs or moral convictions. See INA section 212(a)(1)(A)(ii). 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. See INA section 212(a)(1)(A)(iii). 4. I am a drug abuser or drug addict as described in U.S. Department of Health and Human Services (HHS) regulations. See INA section 212(a)(1)(A)(iv); 42 CFR 32. 5. I have been convicted of or admitted to the essential elements of a crime of moral turpitude (other than a purely political offense). See INA section 212(a)(2)(A)(i)(I). 6. I have been convicted of or admitted to the essential elements of a violation of (or I have attempted or conspired to violate) any controlled substance law or regulation of a U.S. state, the United States, or a foreign country. See INA section 212(a)(2)(A)(i)(II). 7. 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. See INA section 212(a)(2)(B). 8. I have engaged in prostitution in the past 10 years or am coming to the United States to engage in prostitution. See INA section 212(a)(2)(D)(i). [Page 3] 9. I directly or indirectly procure or import (or attempt to procure or import) prostitutes or persons for the purpose of prostitution (including receiving any proceeds or money from prostitution), or I have done so in the past 10 years. See INA section 212(a)(2)(D)(ii). 10. I came to the United States or I am coming to the United States to engage in any other commercialized vice, such as illegal gambling, prostitution, bootlegging, narcotics, or the sale of child pornography. See INA section 212(a)(2)(D)(iii). 11. I have exercised immunity (diplomatic or otherwise) to avoid being prosecuted for a serious criminal offense in the United States. See INA section 212(a)(2)(E). 12. I have been involved in human trafficking activity inside or outside the United States, or I am the spouse, son, or daughter of a person involved in human trafficking activity and have obtained some benefit from that activity within the last five years. See INA section 212(a)(2)(H). 13. I engage, have engaged, or intend to engage in a money laundering offense as described in 18 U.S.C. section 1956 or 1957. See INA section 212(a)(2)(I). 14. 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. See INA section 212(a)(3)(D). 15. I have used or recruited child soldiers in violation of 18 U.S.C. section 2442. See INA section 212(a)(3)(G). 16. I am present in the United States without being admitted or paroled. See INA section 212(a)(6)(A). 17. I did not attend or did not remain at a removal proceeding to determine my inadmissibility or deportability. See INA section 212(a)(6)(B). 18. I have sought to obtain an immigration benefit by fraud or by concealing or misrepresenting a material fact. See INA section 212(a)(6)(C)(i). 19. I falsely claimed to be a U.S. citizen. See INA section 212(a)(6)(C)(ii). 20. I have been a stowaway on a vessel or aircraft arriving in the United States. See INA section 212(a)(6)(D). 21. I have knowingly encouraged, induced, assisted, abetted, or aided any foreign national to enter or try to enter the United States illegally (alien smuggling). See INA section 212(a)(6)(E)(i). 22. I am subject to a civil penalty because I was the subject of a final order for violation of INA section 274C (document fraud). See INA section 212(a)(6)(F). 23. I violated a term or condition of my student visa status. See INA sections 212(a)(6)(G) and 214(l). 24. I am permanently ineligible for U.S. citizenship because I evaded military service. See INA sections 212(a)(8)(A) and 101(a)(19). 25. 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. See INA section 212(a)(8)(B). 26. I was previously removed from the United States. See INA section 212(a)(9)(A). 27. I am subject to the 3-year bar to admissibility because I was unlawfully present in the United States for more than 180 days before departing the United States. See INA section 212(a)(9)(B)(i)(I) . 28. I am subject to the 10-year bar to admissibility because I was unlawfully present in the United States for one year or more before departing the United States. See INA section 212(a)(9)(B)(i)(II). 29. 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 INA section 212(a)(9)(C). 30. I have practiced polygamy since I entered the United States or I intend to practice polygamy in the United States. See INA section 212(a)(10)(A). 31. I am accompanying another person who is inadmissible after being certified to be helpless under INA section 232(c) and I am inadmissible because that other person requires my protection or guardianship. See INA section 212(a)(10)(B). 32. I have been involved in detaining, retaining, or withholding a U.S. citizen child outside the United States from a person who has been granted custody of the child, or I am the spouse, parent, sibling, or agent of someone who has detained, retained, or withheld such a child. See INA section 212(a)(10)(C). 33. I voted in violation of a Federal, state, or local constitutional provision, statute, ordinance, or regulation. See INA section 212(a)(10)(D). 34. I am a former citizen of the United States who renounced my citizenship to avoid paying taxes in the United States. See INA section 212(a)(10)(E). 35. Other (specify): [Page 4] Your Inadmissibility Statement In the space provided in Item Number 36., provide a statement and 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 8. Additional Information or attach a separate letter. If you include a separate letter, indicate in Item Number 36. below that you are attaching a letter. 36. [space for explanation] 37. I request a waiver of the grounds of inadmissibility listed above for the following reasons (select all applicable boxes and provide an explanation in Item Number 38.): For Humanitarian Reasons To Assure Family Unity In the Public Interest [delete] In the space provided in Item Number 38., provide an explanation for why you are requesting a waiver on the grounds indicated in Item Number 37. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 38. [space for explanation] In the space provided in Item Number 39., 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. For more information on discretion, see the Form I-602 Instructions. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 39. [space for explanation]
Pages 2-3, Part 3.	[Page 2] PART 3. To be completed for applicants with active or suspected tuberculosis or who have had a physical or mental disorder and behavior associated with the disorder. A. Statement by Applicant Upon admission to the United States I will: 1. Go directly to the physician or health facility named in Part B below; and 2. Present Copies of diagnostic tests used in the medical examination to substantiate the diagnosis; and 3. Submit to counseling and such examinations, treatment, and medical regimen as may be required; and 4. Remain under prescribed treatment or observation whether on inpatient or outpatient basis, until I am discharged. Signature: Date: NOTE to Applicant’s Sponsor in United States: Arrange for medical care of the applicant and have the physician complete Section B below. B. Statement by Physician and/or Health Facility This section of Form I-602 may be executed by a private physician, health department, other public or private health facility, or military hospital. NOTE: Upon arrival of the applicant in the United States, Form CDC 75.18, Report on Alien With Tuberculosis Waiver, will be sent to the address given below. I agree to supply any treatment or observation necessary for the proper management of the applicant’s tuberculosis condition. I agree to submit Form CDC 75.18 to the health officer named below (Section C) either (a) within 30 days of the applicant’s reporting for care, indicating presumptive diagnosis, test results, and plans for future care of the applicant; or (b) 30 days after receiving Form CDC 75.18, if the applicant has not reported. (NOTE: Military Hospitals should submit this form directly to the Centers for Disease Control, Atlanta, GA 30333.) Satisfactory financial arrangements have been made. (NOTE: This statement does not relieve the applicant of submitting such evidence as the U.S. Consulate may require to establish that the applicant is not likely to become a public charge.) I represent: (Check the appropriate box and give the complete name and address of the facility.) 1. [ ] Local Health Department Outpatient Clinic 2. [ ] Military Hospital 3. [ ] Other Public or Private Health Facility 4. [ ] Private Practice Address: (If military, enter name and address of receiving hospital) Signature of Physician: Date: NOTE to Applicant’s Sponsor in United States: If medical care will be provided by a physician who checked Box 3 or 4 in Section B above, have Section C completed by the local or State health officer who has jurisdiction in the area where the applicant plans reside in the United States. Provide the health officer with the address where the applicant plans to reside in the United States.	[Page 4] Part 3. Applicants Who Have or Had a Physical or Mental Disorder and Behavior Associated with the Disorder Complete Item Numbers 1.a. - 8.b. if you have or had a physical or mental disorder and behavior associated with the disorder that has posed or may pose a threat to the property, safety, or welfare of yourself or others. Statement by Applicant In the United States, I will: Go directly to the physician or health facility named in the Physician’s or Health Facility’s Statement; present copies of diagnostic tests used in the medical examination to prove the diagnosis; submit to counseling and any examinations, treatment, and medical regimen that may be required; and remain under prescribed treatment or observation, whether on inpatient or outpatient basis, until I am discharged. Applicant’s Signature 1.a. Applicant’s Signature 1.b. Date of Signature (mm/dd/yyyy) [delete] Physician’s or Health Facility’s Statement NOTE: This section must be completed and signed by a private physician or representative of a public or private health facility where the applicant will receive treatment in the United States. I agree to supply any treatment or observation necessary to properly manage the applicant’s physical or mental health condition. [delete] I represent a/an (select the appropriate box and provide the complete name and address of the facility): 2.a. [ ] Local Health Department Outpatient Clinic [delete] 2.b. [ ] Other Public or Private Health Facility 2.c. [ ] Private Practice [Page 5] Physician’s or Health Facility’s Physical Address 3. Name of Facility 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.e. ZIP Code 4.f. Province 4.g. Postal Code 4.h. Country Physician’s Contact Information 5. Daytime Telephone Number 6. Email Address (if any) Physician’s Signature 7.a. Physician’s Family Name (Last Name) 7.b. Physician’s Given Name (First Name) 8.a. Physician’s Signature 8.b. Date of Signature [delete]
Pages 2-3, Part 3.	[Page 3] C. Endorsement by Local or State Health Officer Endorsement signifies recognition of the physician or facility for the purpose of providing care for tuberculosis. If the facility or physician who signed in Section B is not in your health jurisdiction and is not familiar to you, you may wish to contact the health office responsible for the jurisdiction of the facility or physician prior to endorsing. Enter name and address of the local health department to which Form CDC 75.18, Notice of Arrival of Alien With Tuberculosis Waiver, will be sent when the applicant arrives in the United States. Local Health Department Address: Signature: Date:	[Page 5] Part 4. Applicants with a Class A Tuberculosis Condition (As Defined by HHS Regulations) Complete Item Numbers 1.a. - 15. if you have a Class A Tuberculosis condition (as defined by HHS regulations). Statement by Applicant In the United States, I will: Go directly to the health department named in the Local (City or County) Health Department’s Statement; present all X-rays used in the visa medical examination to prove the diagnosis; submit to any examinations, treatment, isolation, and medical regimen that may be required; and remain under the prescribed treatment or observation, whether on an inpatient or outpatient basis, until I am discharged. Applicant’s Signature 1.a. Applicant’s Signature 1.b. Date of Signature (mm/dd/yyyy) Local (City or County) Health Department’s Statement [delete] NOTE: This statement must be completed by the physician at the local health department in the area where the applicant plans to reside. I agree to supply any treatment or observation necessary to properly manage and provide continued care of the applicant's tuberculosis condition. Within 30 days of the applicant reporting for care, I agree to submit a summary of my initial evaluation of the applicant’s condition, indicate the presumptive diagnosis, and provide test results and plans for the applicant’s future care to the state health department official named in the State Health Department Official’s Endorsement 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 applicant if he or she has not reported within 30 days after receiving notice from the Division of Global Migration and Quarantine, CDC. I represent (select the appropriate box and provide the complete name, address, contact information, and signature of the health department): [delete] 2.a. [ ] City Health Department 2.b. [ ] County Health Department [Page 6] Local (City or County) Health Department’s Name and Physical Address 3. Name of Local (City or County) Health Department 4.a. Street Number and Name 4.b. Apt. Ste. Flr. 4.c. City or Town 4.d. State 4.e. ZIP Code Physician’s Contact Information 5. Daytime Telephone Number 6. Email Address (if any) Physician’s Signature 7.a. Physician’s Family Name (Last Name) 7.b. Physician’s Given Name (First Name) 8.a. Physician’s Signature 8.b. Date of Signature (mm/dd/yyyy) 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 Local (City or County) Health Department’s Statement and State Health Department Official’s Endorsement sections. Provide the following information. Address where you (the sponsor) or the applicant plan to reside in the United States. 9.a. Street Number and Name 9.b. Apt. Ste. Flr. 9.c. City or Town 9.d. State 9.e. ZIP Code State Health Department Official’s Endorsement NOTE: The state health department official in the area where the applicant plans to reside should complete this statement. By signing this endorsement, I recognize that the local health department that completed the Local (City or County) Health Department’s Statement section will provide care and treatment of the applicant's Tuberculosis condition, and that the local health department is within my jurisdiction. This endorsement also signifies recognition that the applicant will be residing within my state's health jurisdiction. State Health Department Official’s Signature 10.a. State Health Department Official’s Family Name (Last Name) 10.b. State Health Department Official’s Physician’s Given Name (First Name) 11.a. Signature of State Health Department Official 11.b. Date of Signature (mm/dd/yyyy) [Page 7] State Health Department Official’s Name and Physical Address 12. Name of State Health Department 13.a. Street Number and Name 13.b. Apt. Ste. Flr. 13.c. City or Town 13.d. State 13.e. ZIP Code State Health Department Official’s Contact Information 14. Daytime Telephone Number 15. Email Address (if any)
Page 4, USCIS Privacy Act Statement	[Page 4] USCIS Privacy Act Statement AUTHORITIES: The information requested on this application, and the associated evidence, is collected under Sections 207 and 209 of the Immigration and Nationality Act, as amended, as well as 8 CFR 207.3. PURPOSE: The primary purpose for providing the requested information on this application is for a refugee who has been found inadmissible to the United States for reasons such as a criminal conviction or certain health conditions to apply for a waiver of such inadmissibility on grounds of humanitarian reasons, family unity or national interest. DHS will use the information you provide to grant or deny the waiver. DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, ant any requested evidence, may delay a final decision or result in denial of the waiver. ROUTINE USES: DHS may share the information you provide on this application with other Federal, state, local, and foreign government agencies and authorized organizations. DHS follows approved routine uses described in the associated published system of records notice [DHS/USCIS-007-Benefits Information System and DHS/USCIS-001-Alien File, Index, and National File Tracking System of Records] which you can find at www.dhs.gov/privacy. DHS may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.	[delete]
Page 3, Paperwork Reduction Act	[Page 3] Paperwork Reduction Act An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 15 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington DC 20529-2140. OMB No. 1615-0069. Do not mail your application to this address.	[delete]
New		[Page 7] Part 5. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-602 Instructions before completing this section. 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 6. 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 7., [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 law. 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.
New		[Page 8] Part 6. 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 5., 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)
New		[Page 8] Part 7. 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) [Page 9] 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, or Form G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States, 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)
New		[Page 10] Part 8. 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.a. Family Name (Last Name) [Auto-populated field] 1.b. Given Name (First Name) [Auto-populated field] 1.c. Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]

1