Form I-212 Application for Permission to Reapply for Admission into

Application for Permission to Reapply for Admission
Into the United States After Deportation or Removal
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-212
OMB No. 1615-0018
Expires 04/30/2020

For DHS Use Only
Alien Registration Number

Fee Stamp

Action Block

AInitial Receipt

Transferred In

Approved

DRAFT
Not for
Production
05/13/2020
Relocated Returned

Remarks

INA 212(a)(9)(A) for Advance
Approval
INA 212(a)(9)(A)
INA 212(a)(9)(C)

Denied

DHS Office Name/Location

Transferred Out

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)

► START HERE - Type or print in black ink.

Part 1. Information About You
1.

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

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

4.c. Middle Name

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

Other Names Used
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 8.
Additional Information.
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name

Mailing Address

NOTE: If you are outside the United States, provide a U.S.
mailing address, if available. If a U.S. mailing address is not
available, provide your mailing address abroad.
5.a. In Care Of Name (if any)

5.b. Street Number
and Name
5.c.

Ste.

Flr.

5.d. City or Town
5.e. State

5.f.

ZIP Code

5.g. Province
5.h. Postal Code
5.i.

Form I-212 04/27/18

Apt.

Country

Page 1 of 10

Part 1. Information About You (continued)
6.

Is your mailing address the same address where you
currently live (physical address)?
Yes
No
If you answered "No" to Item Number 6., provide your
current physical address in Item Numbers 7.a. - 7.f.

Physical Address

Apt.

Ste.

7.c. City or Town

DRAFT
Not for
Production
05/13/2020
17.a. City or Town

Flr.

17.b. Country

Province

If you are seeking consent to reapply in connection with your
application to adjust your status to that of a lawful permanent
resident, provide information in Item Numbers 18.a. - 18.c.

7.g. Postal Code
7.h. Country

18.a. USCIS Receipt Number (if any)

Other Information About You
8.

18.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

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

9.

The Department of State (DOS) Consular Case Number
(if available)

7.e. ZIP Code

7.d. State
7.f.

16.

The Location of the U.S. Embassy or U.S. Consulate Where
Your Application for an Immigrant Visa is Being or Will Be
Made

7.a. Street Number
and Name
7.b.

If you seek an immigrant or nonimmigrant visa and you are or
will file your application for consent to reapply with your
immigrant or nonimmigrant visa application, provide the
information requested in Item Numbers 16. - 17.b.

18.c. Date Filed (mm/dd/yyyy)

U.S. Online Account Number (if any)
►

10.

Gender

Male

11.

Date of Birth (mm/dd/yyyy)

12.

City or Town of Birth

19.

Are you submitting Form I-601, Application for Waiver
of Grounds of Inadmissibility, along with this application?

Female

Yes

No

If you answered "No," provide the information requested
in Item Numbers 20.a. - 20.c. about previously filed
Forms I-601 (if any):
20.a. USCIS Receipt Number for Form I-601 (if any)

13.

State or Province of Birth (if applicable)
20.b. Where did you file your application (for example,
"USCIS Office Name" or "Lockbox")?

14.

Country of Birth

15.

Country of Citizenship or Nationality

Form I-212 04/27/18

20.c. Date Filed (mm/dd/yyyy)

Page 2 of 10

Part 2. Reasons You Are Filing Form I-212
If you are inadmissible to the United States for the following
reason, select “Yes” and then select the appropriate boxes. If
you need extra space to complete this section, use the space
provided in Part 8. Additional Information.

Removal as an Arriving Alien (INA Section
212(a)(9)(A)(i))

7.b. State

Entry After Unlawful Presence in the Aggregate of
1 Year (INA Section 212(a)(9)(C)(i)(I))

8.

I have only been removed once, and my last removal
was less than five years ago.

1.c.

I have been removed at least two or more times, and
my last removal was less than 20 years ago.

1.d.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 8. Additional
Information and include the required evidence.

2.

7.a. City or Town

DRAFT
Not for
Production
05/13/2020

1.a. I have been removed as an arriving alien in expedited
removal proceedings under INA section 235(b)(1) or I
was removed at the end of proceedings under INA section
240 as an arriving alien.
Yes
No
1.b.

Location From Where You Were Removed

Date You Were Removed From the United States
(mm/dd/yyyy)

I entered or attempted to enter the United States without
being admitted or paroled, after having been unlawfully
present in the United States on or after April 1, 1997, for a
period of more than one year, in the aggregate.
Yes

No

NOTE: If you answered "Yes" to Item Number 8., list
all the time periods during which you were unlawfully
present in the United States (including any periods in
which you overstayed your lawful status). Begin with
your most recent period of unlawful presence. Also
attach evidence demonstrating that you have remained
outside the United States for 10 years since your last
departure.

Periods of Unlawful Presence
9.a. From (mm/dd/yyyy)

Location From Where You Were Removed
3.

City or Town

9.b. To (mm/dd/yyyy)

10.

4.

State

Date You Departed the United States After Your Period
of Unlawful Presence (mm/dd/yyyy)

Location Where You Departed the United States After Your
Period of Unlawful Presence

Removal as a Deportable Alien (INA Section
212(a)(9)(A)(ii))
5.a. I have been removed as a deportable alien under INA
section 240 or any other provision of the law, or I
departed the United States while an order of removal was
outstanding.
Yes
No
5.b.

I have only been removed once and my removal was
less than 10 years ago.

5.c.

I have been removed two or more times, and my last
removal was less than 20 years ago.

5.d.

I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
aggravated felony convictions in Part 8. Additional
Information and include the required evidence.

6.

11.a. City or Town

11.b. State

Location Where You Reentered or Attempted to Reenter the
United States
12.a. City or Town

12.b. State

13.

Date You Attempted to Unlawfully Enter or Reenter the
United States After Period of Unlawful Presence
(mm/dd/yyyy)

Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)

Form I-212 04/27/18

Page 3 of 10

Part 2. Reasons You Are Filing Form I-212
(continued)

U.S. Citizen or Lawful Permanent Resident Family
Members (if any)

Entry After Removal (INA Section
212(a)(9)(C)(i)(II))

NOTE: If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.

14.

I entered or attempted to enter the United States without
being admitted or paroled after having been excluded,
deported, or removed.
Yes
No

DRAFT
Not for
Production
05/13/2020

NOTE: If you answered “Yes” to Item Number 14., list
all the dates when you were excluded, deported, or
removed from the United States. If you need extra space
to complete this section, use the space provided in Part 8.
Additional Information.
15.

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

Date You Were Excluded, Deported, or Removed From
the United States (mm/dd/yyyy)

3.c. Middle Name
3.d. Relationship

My relative is (Select one):
A lawful permanent resident.
4.a.
4.b.

A U.S. citizen.

Location Where You Reentered or Attempted to Reenter the
United States After Your Exclusion, Deportation, or Removal
16.a. City or Town

16.b. State

17.

Date You Entered or Attempted to Reenter the United
States After Exclusion, Deportation, or Removal
(mm/dd/yyyy)

Part 3. Reasons For Your Request For
Permission to Reapply

If the Department of Homeland Security (DHS) permits you to
reenter the United States, what immigration status will you seek?

Part 4. Additional Information if Filing with
CBP

If you are filing this application with Customs and Border
Protection (CBP), provide the information requested in Item
Numbers 1.a. - 40.c.

Address History

Provide physical addresses for everywhere you have lived
during the last ten years, whether inside or outside the United
States. Provide your current address first. If you are unsure of
the exact date, provide the closest approximate date to the best
of your knowledge. If you need extra space to complete this
section, use the space provided in Part 8. Additional
Information.
Physical Address 1 (current address)

1.a.

Permanent Resident

1.b.

Visitor

1.a. Street Number
and Name

1.c.

Student

1.b.

1.d.

Other (Explain)

2.

Explain Why You Would Like to Reenter the United
States

NOTE: If you need extra space to complete this section,
use the space provided in Part 8. Additional
Information.

Apt.

Ste.

Flr.

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

1.e. ZIP Code

Province

1.g. Postal Code
1.h. Country

Dates of Residence
2.a. From (mm/dd/yyyy)

Form I-212 04/27/18

Page 4 of 10

Part 4. Additional Information if Filing with
CBP (continued)
2.b. To (mm/dd/yyyy)

3.f.

Ste.

Flr.

DRAFT
Not for
Production
05/13/2020
6.e. ZIP Code

6.d. State

Ste.

Flr.

6.f.

Province

6.g. Postal Code

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

Apt.

6.c. City or Town

3.a. Street Number
and Name
Apt.

6.a. Street Number
and Name
6.b.

Physical Address 2

3.b.

Address of Employer or Company

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

6.h. Country

7.

Your Occupation

Dates of Employment

8.a. From (mm/dd/yyyy)

Dates of Residence

8.b. To (mm/dd/yyyy)

4.a. From (mm/dd/yyyy)

Employer 2

4.b. To (mm/dd/yyyy)

9.

Name of Employer or Company

Employment History

Provide your employment history for the last five years,
whether inside or outside the United States. Provide the most
recent employment first. If you are unsure of the exact
employment date, provide the closest approximate date to the
best of your knowledge. If you need extra space to complete
this section, use the space provided in Part 8. Additional
Information.

Address of Employer or Company

Employer 1 (current or most recent)

10.d. State

5.

10.a. Street Number
and Name

10.b.

Apt.

Ste.

Flr.

10.c. City or Town
10.e. ZIP Code

Name of Employer or Company
10.f. Province
10.g. Postal Code
10.h. Country

11.

Your Occupation

Dates of Employment
12.a. From (mm/dd/yyyy)
12.b. To (mm/dd/yyyy)

Form I-212 04/27/18

Page 5 of 10

Part 4. Additional Information if Filing with
CBP (continued)
Information About Your Parents
Information About Your Mother
Mother's Legal Name
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
13.c. Middle Name

14.c. Middle Name

City or Town of Birth

24.

Country of Birth

25.

Current City or Town of Residence (if living)

DRAFT
Not for
Production
05/13/2020

Mother's Name at Birth (if different than above)
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)

23.

15.

Date of Birth (mm/dd/yyyy)

16.

City or Town of Birth

17.

Country of Birth

18.

Current City or Town of Residence (if living)

19.

Current Country of Residence (if living)

26.

Current Country of Residence (if living)

Information About Your Marital History

27.

What is your current marital status?
Single, Never Married

Legally Separated

Married

Marriage Annulled

Divorced

Other

Widowed

28.

How many times have you been married (including
annulled marriages and marriages to the same person)?

Information About Your Current Marriage
(including if you are legally separated)

If you are currently married, provide the following information
about your current spouse.
Current Spouse's Legal Name

Information About Your Father

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

Father's Legal Name

29.c. Middle Name

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

30.

A-Number (if any) ► A-

31.

Current Spouse's Date of Birth (mm/dd/yyyy)

32.

Date of Marriage to Current Spouse (mm/dd/yyyy)

20.c. Middle Name
Father's Name at Birth (if different than above)
21.a. Family Name
(Last Name)
21.b. Given Name
(First Name)

Current Spouse's Place of Birth
33.a. City or Town

21.c. Middle Name
22.

Date of Birth (mm/dd/yyyy)

Form I-212 04/27/18

33.b. State or Province

Page 6 of 10

Part 4. Additional Information if Filing with
CBP (continued)

Place Where Marriage with Prior Spouse Legally Ended
40.a. City or Town

33.c. Country
40.b. State or Province
Place of Marriage to Current Spouse
34.a. City or Town

34.b. State or Province

34.c. Country

DRAFT
Not for
Production
05/13/2020

Information About Prior Marriages (if any)

If you have been married before, whether in the United States or
in any other country, provide the following information about
your prior spouse. If you have had more than one previous
marriage, use the space provided in Part 8. Additional
Information to provide the information below.

40.c. Country

Part 5. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

NOTE: Read the Penalties section of the Form I-212
Instructions before completing this part.

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 6. read to me every
question and instruction on this application and my

Prior Spouse's Legal Name (provide family name before
marriage)
35.a. Family Name
(Last Name)
35.b. Given Name
(First Name)
35.c. Middle Name
36.

Prior Spouse's Date of Birth (mm/dd/yyyy)

37.

Date of Marriage to Prior Spouse (mm/dd/yyyy)

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 7.,

prepared this application for me based only upon
information I provided or authorized.

Applicant's Contact Information
Place of Marriage to Prior Spouse

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

38.a. City or Town

38.b. State or Province

38.c. Country

39.

Date Marriage with Prior Spouse Legally Ended
(mm/dd/yyyy)

Form I-212 04/27/18

Page 7 of 10

Part 5. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address
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.

3.a. Street Number
and Name

DRAFT
Not for
Production
05/13/2020

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

3.b.

Apt.

Ste.

Flr.

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

3.f.

3.e. ZIP Code

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)

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.

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)

Interpreter's Certification

I certify, under penalty of perjury, that:
I am fluent in English and
,
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)

Form I-212 04/27/18

Page 8 of 10

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant

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.

Provide the following information about the preparer.

Preparer's Full Name

DRAFT
Not for
Production
05/13/2020

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)

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, 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 Mailing Address

Preparer's Certification

3.a. Street Number
and Name

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.

3.b.

Apt.

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

Province

3.g. Postal Code
3.h. Country

Ste.

Flr.

3.e. ZIP Code

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-212 04/27/18

Preparer's Signature

8.a. Preparer's Signature

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

Page 9 of 10

5.a. Page Number

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

5.b. Part Number

5.c. Item Number

5.d.

DRAFT
Not for
Production
05/13/2020

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

4.d.

Form I-212 04/27/18

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 10 of 10