Form I-601a Application for Provisional Unlawful Presence Waiver

Application for Provisional Unlawful Presence Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services

For
USCIS
Use
Only

Initial Receipt

Fee Stamp

Resubmitted

Relocated

OMB No. 1615-0123
Expires 02/28/2021

Action Block

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Received

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

Select this box if
Form G-28 is
attached to represent
the applicant.

USCIS
Form I-601A

Sent

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

Your U.S. Mailing Address

Provide the following information about yourself.

7.a. In Care Of Name

1.

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

2.

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

3.

(USPS ZIP Code Lookup)

USCIS Online Account Number (if any)
►

Your Full Name
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name

Other Names Used (if any)
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

7.b. Street Number
and Name
7.c.

Apt.

Ste.

Flr.

7.d. City or Town

7.e. State
8.

7.f.

ZIP Code

Is your current physical address the same as your mailing
address?
Yes
No
If you answered "No" to Item Number 8., provide your
physical address in Item Numbers 9.a. - 9.e.

Your U.S. Physical Address
9.a. Street Number
and Name
9.b.

Apt.

Ste.

Flr.

9.c. City or Town
9.d. State

9.e. ZIP Code

Other Information
10.

Gender

11.

Date of Birth (mm/dd/yyyy)

Male

Female

6.c. Middle Name
Form I-601A 02/13/19

Page 1 of 9

Part 1. Information About You (continued)
12.

23.a. Place or Port-of-Entry (Actual or approximate city or town)

City or Town of Birth
23.b. State

13.

Country of Birth

14.

Country of Citizenship or Nationality

24.a. From (On or about mm/dd/yyyy)
24.b. To (On or about mm/dd/yyyy)
25.

Immigration Status (At the time of entry)

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15.a. Mother's Family Name (Last Name)

26.

15.b. Mother's Given Name (First Name)

27.

Date of Entry (On or about mm/dd/yyyy)

18.a. Place or Port-of-Entry (Actual or approximate city or town)

18.b. State
19.

You were previously in the United States as follows:

20.a. Place or Port-of-Entry (Actual or approximate city or town)

20.b. State
21.a. From (On or about mm/dd/yyyy)
21.b. To (On or about mm/dd/yyyy)
22.

Immigration Status (At the time of entry)

Form I-601A 02/13/19

Are you currently in removal, exclusion, or deportation
proceedings in which there is no final order issued by the
immigration judge, the Board of Immigration Appeals, a
DHS officer, or a Federal court yet? (This includes
proceedings under INA section 239, an exclusion or
deportation proceeding initiated before April 1,1997, a
Visa Waiver Program removal proceeding under INA
section 217, expedited removal under INA 235, and a
request for a judicial removal order under INA section
238(c))?
Yes
No
If you answered “No” to Item Number 27., go to Item
Number 29.a. If you answered “Yes” to Item Number
27., select the statement below (either Item Number
28.a. or 28.b.) that most accurately describes your current
situation.

Immigration Status (At the time of entry)

Your Previous Entries Into the United States

No

Your Immigration or Criminal History

Your Last Entry Into the United States
17.

Yes

If you answered "Yes" to Item Number 26., include the
place of entry, dates, and your immigration status at the
time of entry for any other prior entries in the space
provided in Part 9. Additional Information.

16.a. Father's Family Name (Last Name)
16.b. Father's Given Name (First Name)

Are there other previous entries?

28.a.

I am in removal, exclusion, or deportation
proceedings that are administratively closed and, at
the time of filing my Form I-601A, have not been
placed back on EOIR's calendar to continue my
removal, exclusion, or deportation proceedings.

NOTE: You may be eligible for a provisional
unlawful presence waiver. Provide a copy of the
administrative closure order. Also, if U.S.
Citizenship and Immigration Services (USCIS)
approves your provisional unlawful presence
waiver, it is important that you resolve your
removal, exclusion, or deportation proceedings
before you depart the United States for your
immigrant visa interview.

Page 2 of 9

Part 1. Information About You (continued)
28.b.

31.

I am currently in removal, exclusion, or deportation
proceedings that are not administratively closed, or
in removal, exclusion, or deportation proceedings
that were administratively closed, but EOIR has
placed my proceedings back on its calendar in order
to continue them.

NOTE: If you answered "Yes" to Item Number 31., you
are ineligible for a provisional unlawful presence waiver.

NOTE: You are ineligible for a provisional
unlawful presence waiver unless your proceedings
are administratively closed at the time you file your
Form I-601A, and the proceedings have not been
put back on EOIR's calendar to continue your
removal, exclusion, or deportation after having been
previously administratively closed.

NOTE: If you answered "Yes" to Item Number 29.a.,
you are ineligible for a provisional unlawful presence
waiver unless you applied for, and USCIS has already
approved, an application for permission to reapply for
admission under INA section 212(a)(9)(A)(iii) and 8 CFR
212.2 on Form I-212, Application for Permission to
Reapply for Admission into the United States after
Deportation or Removal. If you have already applied for
and if USCIS has already granted you permission to
reapply for admission, provide the relevant information in
Item Number 29.b. If you answered "No" to Item
Number 29.a., go to Item Number 31.
29.b. USCIS Receipt Number for Your Approved Form I-212:
NOTE: You may also provide a copy of the approval
notice that USCIS sent to you when it approved your
Form I-212.
30.a. Has DHS served you with a DHS Form I-871, giving you
notice that DHS intends to reinstate a prior deportation,
exclusion, or removal order against you as permitted
under INA section 241(a)(5)?
Yes
No
30.b. If you answered "Yes" to Item Number 30.a., has DHS
served you with a final decision reinstating a prior
deportation, exclusion, or removal order under INA
section 241(a)(5)?
Yes
No

Form I-601A 02/13/19

If you were granted voluntary departure in the past, but
then you withdrew your voluntary departure request or
otherwise terminated voluntary departure you should not
select "Yes" to Item Number 31. In this case you may be
in removal proceedings or you may be the subject of a
final order of removal, deportation, or exclusion. You
should select the statements that apply to you in Item
Numbers 27. - 28.b. or Item Number 29.a. If you filed
a motion to withdraw your voluntary departure request,
please submit a copy with your Form I-601A.

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29.a. Are you currently subject to a final order of removal,
exclusion or deportation? (This includes an order entered
in proceedings under INA section 239, an exclusion or
deportation order entered in proceedings initiated before
April 1, 1997, a Visa Waiver Program removal order
under INA section 217, an expedited removal order under
INA section 235, and a judicial order under INA section
238(c))?
Yes
No

►

Are you currently subject to a grant of voluntary
departure that has not expired and that was granted to you
by the immigration judge or the Board of Immigration
Appeals during removal, exclusion, or deportation
proceedings?
Yes
No

Answer Item Numbers 32. - 38. If you answer "Yes" to any
question in Item Numbers 32. - 38., your application for a
provisional unlawful presence waiver may be denied as a matter
of discretion. For each "Yes" response for Item Numbers 32. 38., provide the location and date of the event and a brief
description in Part 9. Additional Information. For Item
Number 34., if you were arrested but not charged with any
crime or offense, provide a statement or other documentation
from the arresting authority, prosecutor's office, or court to
show that you were not charged with any crime or offense. If
you answer "Yes" to Item Number 35., you must provide all
related court dispositions.
32.

Have you EVER knowingly and willfully given false or
misleading information to a U.S. Government official
while applying for an immigration benefit or to gain entry
or admission into the United States?
Yes
No

33.

Have you EVER been engaged in alien smuggling?
Yes

No

34.

Have you EVER been arrested, cited, or detained by a
law enforcement officer (including immigration and
military officers) in the United States, your home country,
and/or any other country for any reason other than traffic
violations?
Yes
No

35.

Have you EVER been charged, indicted, convicted,
imprisoned, or jailed in the United States, your home
country, and/or any other country for any crime or
offense?
Yes
No

36.

Have you EVER trafficked in or are you NOW trafficking
in any controlled substance?
Yes
No

Page 3 of 9

Part 1. Information About You (continued)
37.

Have you EVER assisted or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
Yes
No

43.

Have you EVER received any type of military,
paramilitary, or weapons training?
Yes

Are you NOW or have you EVER knowingly assisted,
abetted, conspired, or colluded with others in the unlawful
trafficking of any controlled substance?
Yes

38.

42.

No

Are you NOW or have you EVER been engaged in
prostitution?
Yes
No

Answer Item Numbers 39.a. - 45. If you answer "Yes" to any
question in Item Numbers 39.a. - 45., your application for a
provisional unlawful presence waiver may be denied as a
matter of discretion. For each "Yes" response for Item
Numbers 39.a. - 45., provide a complete explanation in
Part 9. Additional Information.

44.

39.a. Acts involving torture or genocide?

Yes

No

39.b. Killing any person?

Yes

No

39.c. Intentionally and severely injuring any person?
Yes

Yes

1.

Not Hispanic or Latino

No

2.

Asian

Black or African American

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

3.

Height

4.

Weight

5.

Eye Color (Select only one box)
Black
Gray
Maroon

40.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No
Have you EVER been a member of, assisted in, or
participated in any group, unit, or organization of any
kind in which you or other persons used any type of
weapon against any person or threatened to do so?

Form I-601A 02/13/19

No

Race (Select all applicable boxes)
White

No

40.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
Yes
No

Yes

Ethnicity (Select only one box)
Hispanic or Latino

39.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No

41.

Have you EVER used any person under 15 years of age
to take part in hostilities, or to help or provide services to
people in combat?
Yes
No

Part 2. Biographic Information

39.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?

Have you EVER:

Have you EVER recruited, enlisted, conscripted, or used
any person under 15 years of age to serve in or help an
armed force or group?
Yes
No

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Have you EVER ordered, incited, called for, committed, assisted,
helped with, or otherwise participated in any of the following:

45.

No

6.

Feet

Inches
Pounds

Blue

Brown

Green
Pink

Hazel
Unknown/Other

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

Black

Blond

Brown
Sandy

Gray
White

Red
Unknown/
Other

Page 4 of 9

Part 3. Information About Your Immigrant
Visa Case

Part 4. Information About Your Qualifying
Relative

Provide the basis on which you are immigrating to the United
States using the check boxes below. (Select only one box)

Provide the following information about the qualifying relative
(the U.S. citizen or Lawful Permanent Resident (LPR) spouse or
parent) who would experience extreme hardship if you were
refused admission to the United States.

1.a.

Diversity Visa Program Selectee or Derivative

1.b.

Immediate Relative Petition (Form I-130)

1.c.

Preference-Based Family Petition (Form I-130),
including Derivatives

1.d.

Employment-Based Petition (Form I-140), including
Derivatives

1.e.

Special Immigrant/Widow Petition (Form I-360),
including Derivatives

Your Qualifying Relative's Full Name and
Relationship to You

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

1.c. Middle Name

If you selected Item Number 1.a. because you are a Diversity
Visa (DV) Program selectee or derivative, provide information
about your (or your spouse's or parent's) DV case:

2.a.

U.S. Citizen Spouse

2.b.

U.S. Citizen Parent

2.a. DOS DV Case Number (KCC Case Number)

2.c.

LPR Spouse

2.d.

LPR Parent

►

DV Program Selectee's Full Name (If you are a derivative and
your parent or spouse is the DV Program Selectee)
2.b. Family Name
(Last Name)
2.c. Given Name
(First Name)
2.d. Middle Name

If you selected Item Numbers 1.b., 1.c., 1.d., or 1.e. provide
the following information about the approved immigrant visa
petition (Form I-130, Form I-140, or Form I-360) that was filed
on your (or your spouse's or parent's) behalf, or that you used to
self-petition on your behalf, that is your basis to immigrate and
the related Department of State (DOS) immigrant visa
application.
3.a. USCIS Receipt Number
►
3.b. DOS Consular Case Number (NVC Case Number)
►

Petitioner Name (Provide the full name of the family member or
the company who petitioned for you (or your spouse or parent).)
3.c. Family Name
(Last Name)
3.d. Given Name
(First Name)

Your Other Qualifying Relative

3.

Do you have more than one qualifying relative (U.S. citizen
or LPR spouse or parent)?
Yes
No
If you answered "Yes" to Item Number 3., provide the
other qualifying relative's name and your relationship to
the qualifying relative in Item Numbers 4.a. - 5.d.
Also provide evidence of the U.S. citizenship or LPR
status of the other qualifying relative with your
application. See the What Evidence Must I Submit
With Form I-601A section of the Instructions.

Additional Qualifying Relative's Full Name and
Relationship to You

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

4.c. Middle Name
5.a.

U.S. Citizen Spouse

5.b.

U.S. Citizen Parent

5.c.

LPR Spouse

5.d.

LPR Parent

3.e. Middle Name
3.f.

Company or Organization Name

Form I-601A 02/13/19

Page 5 of 9

Part 5. Statement From Applicant
In the space provided, explain in detail why you believe USCIS
should approve your application for a provisional unlawful
presence waiver as a matter of discretion. Provide all of the
reasons you believe support your application for this waiver,
including information about the extreme hardship your
qualifying relatives would experience if you were refused
admission to the United States. If you need extra space to
complete your statement, use the space provided in Part 9.
Additional Information.

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.

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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

,

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

2.

At my request, the preparer named in Part 8.,

,

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.

Form I-601A 02/13/19

Page 6 of 9

Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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

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

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

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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.g. Postal Code
3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

6.a. Applicant's Signature

5.

Interpreter's Mobile Telephone Number (if any)

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

6.

Interpreter's Email Address (if any)

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.

Interpreter's Certification

Applicant's Signature

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)

I certify, under penalty of perjury, that:

I am fluent in English and
,
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

2.

Interpreter's Business or Organization Name (if any)
7.b. Date of Signature (mm/dd/yyyy)

Form I-601A 02/13/19

Page 7 of 9

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)

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.

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1.b. Preparer's Given Name (First Name)
2.

Preparer's Statement

Preparer's Business or Organization Name (if any)

Preparer's Certification

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

Apt.

Ste.

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

Province

3.g. Postal Code
3.h. Country

Flr.

3.e. ZIP Code

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)

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)

Form I-601A 02/13/19

Page 8 of 9

5.a. Page Number

Part 9. 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)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

5.b. Part Number

5.c. Item Number

5.d.

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A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

Form I-601A 02/13/19

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.c. Item Number

7.a. Page Number

7.d.

Page 9 of 9