Form I-690 Application for Waiver of Grounds of Inadmissibility Und

Application for Waiver of Grounds of Inadmissibility Under
Sections 245A or 210 of the Immigration and Nationality Act
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-690
OMB No. 1615-0032
Expires 12/31/2018

For Government Use Only
Alien Registration Number (A-Number of This Applicant):

Action Block

AFee Receipt Number (This application):

DRAFT
NOT FOR
PRODUCTION
08/31/2018

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

Attorney State Bar Number
(if applicable)

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

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

► START HERE - Type or print in black ink.

Read the Instructions before completing this application.

Part 1. Information About You (Applicant)
Your Current Legal Name
1.

Family Name (Last Name)

Given Name (First Name)

Mailing Address
2.

(USPS ZIP Code Lookup)

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

Middle Name (if applicable)

Postal Code

ZIP Code

Country

Is your current mailing address the same as your physical address?

Yes

No

If you answered "No" to Item Number 3., provide your physical address in Item Number 4.

Form I-690 12/23/16 N

Page 1 of 8

Part 1. Information About You (Applicant) (continued)
Physical Address
4.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

DRAFT
NOT FOR
PRODUCTION
08/31/2018

Other Information
5.

7.

City/Town/Village of Birth

Date of Birth (mm/dd/yyyy)

6.

8.

Country of Birth

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

9.

USCIS Online Account Number (if any)

10.

►

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

Part 2. Additional Information About You
1.

I am applying for a waiver for this primary application:

Permanent Residence (Form I-698, LIFE Act Form I-485)

2.

4.

Date You Filed the Primary Application
(mm/dd/yyyy)

3.

Temporary Residence (Form I-687 or Form I-700)

Receipt Number for Primary Application
►

I am applying for a waiver of (select all applicable boxes):

INA section (Please see the Instructions for more information on these sections.)

5.

212 (a)(1)(A)(i)

212(a)(2)(I)

212(a)(6)(G)

212(a)(9)(C)(i)(II)

212 (a)(1)(A)(ii)

212(a)(4)

212(a)(8)(A)

212 (a)(10)(A)

212 (a)(1)(A)(iii)

212(a)(6)(B)

212(a)(8)(B)

212 (a)(10)(B)

212 (a)(1)(A)(iv)

212(a)(6)(C)(i)

212(a)(9)(A)(i)

212 (a)(10)(C)

212(a)(2)(H)

212(a)(6)(C) (ii)

212(a)(9)(A)(ii)

212 (a)(10)(D)

212(a)(2)(I)

212(a)(6)(D)

212(a)(9)(B)(i)(I)

212 (a)(10)(E)

212(a)(4)

212(a)(6)(E)

212(a)(9)(B)(i)(II)

Other Inadmissibility - Specify below

212(a)(6)(B)

212(a)(6)(F)

212(a)(9)(C)(i)(I)

List the specific reasons why you are inadmissible in the space below.

Form I-690 12/23/16 N

Page 2 of 8

Part 2. Additional Information About You (continued)
6.

List all immediate relatives in the United States (parents, spouse, and children). If you need extra space to complete this section,
use the space provided in Part 6. Additional Information.
A. Relative 1
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

DRAFT
NOT FOR
PRODUCTION
08/31/2018
Date of Birth (mm/dd/yyyy)

Relationship

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

B. Relative 2

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy)

Relationship

ZIP Code

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

C. Relative 3
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy)

Relationship

ZIP Code

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

Form I-690 12/23/16 N

Page 3 of 8

Part 2. Additional Information About You (continued)
D. Relative 4
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

DRAFT
NOT FOR
PRODUCTION
08/31/2018
Date of Birth (mm/dd/yyyy)

Relationship

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

7.

Describe the family unity, humanitarian, or public interest reasons or considerations for why U.S. Citizenship and Immigration
Services (USCIS) should grant your waiver. If you need extra space to complete this section, use the space provided in Part 6.
Additional Information.

Part 3. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-690 Instructions before completing this section.

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.

2.

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 4. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am fluent, and I understood
everything.

Applicant's Statement Regarding the Preparer
,

At my request, the preparer named in Part 5.,
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)

Form I-690 12/23/16 N

4.

Applicant's Mobile Telephone Number (if any)

Page 4 of 8

Part 3. Applicant's Statement, Contact Information, Declaration, Certification, and Signature
(continued)
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
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 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.

DRAFT
NOT FOR
PRODUCTION
08/31/2018

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 may deny your application.

Part 4. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name
1.

2.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

Form I-690 12/23/16 N

5.

Interpreter's Mobile Telephone Number (if any)

Page 5 of 8

Part 4. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Certification
I certify, under penalty of perjury, that:
, which is the same language provided in Part 3.,

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.

Interpreter's Signature
7.

DRAFT
NOT FOR
PRODUCTION
08/31/2018
Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 5. 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.

2.

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

Form I-690 12/23/16 N

5.

Preparer's Mobile Telephone Number (if any)

Page 6 of 8

Part 5. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other
Than the Applicant (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.

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.

DRAFT
NOT FOR
PRODUCTION
08/31/2018

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-690 12/23/16 N

Date of Signature (mm/dd/yyyy)

Page 7 of 8

Part 6. Additional Information
If you need extra space to provide any additional information within this application, use the space below. If you need more space
than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper.
Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item
Number to which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A.

Given Name (First Name)

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Middle Name

DRAFT
NOT FOR
PRODUCTION
08/31/2018
D.

4.

A.

D.

5.

A.

D.

6.

A.

D.

7.

A.

D.

Form I-690 12/23/16 N

Page 8 of 8