Form I-602 Application by Refugee for Waiver of Inadmissibility Gro

Application by Refugee for
Waiver of Inadmissibility Grounds

USCIS
Form I-602

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0069
Expires 07/31/2022

For USCIS Use Only
Initial Receipt

Resubmitted

Relocated

Received/Sent

Action Block

Benefits Category:

Inadmissible Under

Refugee status under INA 207
Adjustment of status as a refugee/asylee under INA 209

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

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

INA 212(a)(1)
INA 212(a)(2)
INA 212(a)(3)

INA 212(a)(6)

INA 212(a)(10)
Other:

INA 212(a)(8)
INA 212(a)(9)

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

Mailing Address

(USPS ZIP Code Lookup)

3.a. In Care Of Name (if any)

Your Full Legal Name
1.a. Family Name (Last Name)

1.b. Given Name (First Name)

3.b. Street Number
and Name
3.c.

Apt.

Ste.

Flr.

3.d. City or Town
1.c. Middle Name
3.e. State

3.f.

ZIP Code

3.g. Province

Place of Birth
2.a. City or Town of Birth

3.h. Postal Code
3.i.

Country

4.

Is your current mailing address the same as your physical
address?
Yes
No

2.b. State or Province of Birth

2.c. Country of Birth

If you answered “No” to Item Number 4., provide your
physical address in Item Numbers 5.a. - 5.h.

Form I-602 Edition 07/23/20

Page 1 of 10

Part 1. Information About You (continued)

Part 2. Reasons for Inadmissibility

Physical Address

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.

5.a. Street Number
and Name
5.b.

Apt.

Ste.

Flr.

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

5.e. ZIP Code

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.

Province

5.g. Postal Code

I believe or I was told that I am inadmissible because (select all
grounds that you believe apply to you):

5.h. Country

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).

Other Information
6.

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

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.

Form I-602 Edition 07/23/20

Page 2 of 10

22.

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).

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 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).

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):

Part 2. Reasons for Inadmissibility (continued)
9.

10.

11.

12.

13.

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).
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).
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).

Form I-602 Edition 07/23/20

Page 3 of 10

Part 2. Reasons for Inadmissibility (continued)
Your Inadmissibility Statement

Part 3. Applicant Who Have or Had a Physical
or Mental Disorder and Behavior Associated with
the Disorder

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.

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.

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.

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
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.):

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

For Humanitarian Reasons
To Assure Family Unity

Physician's or Health Facility's Statement

In the Public Interest

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.

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.

I agree to supply any treatment or observation necessary to
properly manage the applicant's physical or mental health
condition.
I represent a/an (select the appropriate box and provide the
complete name and address of the facility):

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.

2.a.

Local Health Department Outpatient Clinic

2.b.

Other Public or Private Health Facility

2.c.

Private Practice

39.

Form I-602 Edition 07/23/20

Page 4 of 10

Part 3. Applicants Who Have or Had a Physical
or Mental Disorder and Behavior Associated with
the Disorder (continued)
Physician's or Health Facility's Physical Address
3.

Part 4. Applicant 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

Name of Facility

In the United States, I will:
4.a. Street Number
and Name
4.b.

Apt.

Ste.

Flr.

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

4.e. ZIP Code

Province

4.g. Postal Code

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

4.h. Country
1.b. Date of Signature (mm/dd/yyyy)

Physician's Contact Information
5.

6.

Daytime Telephone Number

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)

Local (City or County) Health Department's
Statement
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):

Form I-602 Edition 07/23/20

2.a.

City Health Department

2.b.

County Health Department

Page 5 of 10

Part 4. Applicants with a Class A Tuberculosis
Condition (As Defined by HHS Regulations)
(continued)
Local (City or County) Health Department's Name
and Physical Address
3.

Name of Local (City or County) Health Department

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.

4.a. Street Number
and Name
4.b.

Apt.

9.a. Street Number
and Name

Ste.

Flr.

4.c. City or Town
4.d. State

9.b.

Apt.

Ste.

Flr.

9.c. City or Town
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)

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)

Form I-602 Edition 07/23/20

Page 6 of 10

Applicant's Contact Information

Part 4. Applicants with a Class A Tuberculosis
Condition (As Defined by HHS Regulations)
(continued)

3.

Applicant's Daytime Telephone Number

State Health Department Official's Name and
Physical Address

4.

Applicant's Mobile Telephone Number (if any)

12.

5.

Applicant's Email Address (if any)

Name of State Health Department

13.a. Street Number
and Name
13.b.

Apt.

Applicant's Declaration and Certification

Ste.

Flr.

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.

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)

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.

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

Applicant's Signature

NOTE: Read the Penalties section of the Form I-602
Instructions before completing this section.

6.a. Applicant's Signature

Applicant's Statement

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

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

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.

,
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.

Form I-602 Edition 07/23/20

Page 7 of 10

Interpreter's Signature

Part 6. Interpreter's Contact Information,
Certification, and Signature

7.a. Interpreter's Signature

Provide the following information about the interpreter.
7.b. Date of Signature (mm/dd/yyyy)

Interpreter's Full Name
1.a. Interpreter's Family Name (Last Name)

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

1.b. Interpreter's Given Name (First Name)

Provide the following information about the preparer.
2.

Interpreter's Business or Organization Name (if any)

Preparer's Full Name
1.a. Preparer's Family Name (Last Name)

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

Apt.

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

Ste.

Flr.
2.

Preparer's Business or Organization Name (if any)

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

3.e. ZIP Code

Preparer's Mailing Address
3.f.

Province

3.a. Street Number
and Name

3.g. Postal Code

3.b.

3.h. Country

Apt.

Ste.

Flr.

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

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)

3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

,

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.
Form I-602 Edition 07/23/20

4.

Page 8 of 10

Part 7. 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.

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)

Form I-602 Edition 07/23/20

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.

5.b. Part Number

5.c. Item Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

5.d.

1.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name

2.

6.a. Page Number

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number

6.d.

3.d.

7.a. Page Number
4.a. Page Number

4.b. Part Number

4.c. Item Number
7.d.

4.d.

Form I-602 Edition 07/23/20

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