Information Collection

Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)

IC 6595 under ICR 202006-0920-005 · OMB 0920-0006.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0006 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 422-1 Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form
4 422-1 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADM Attachment C CDC Form 4 422-1.pdf	Form

IC Title:

Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4 422-1	STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY	Attachment C CDC Form 4 422-1.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-02-0102: Alien Mental Waiver Program

FR Citation: 51 FR 42461

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	200	0	200
Annual IC Time Burden (Hours)	33	0	33
Annual IC Cost Burden (Dollars)	3,260	-12,740	16,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.