Form I-191 Application for Relief under Former Section 212(c) of th

Application for Relief Under Former Section 212(c)
of the Immigration and Nationality Act (INA)

USCIS
Form I-191

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

For
USCIS
Use
Only

OMB No. 1615-0016
Expires 11/30/2023

Fee Stamp

Action Block

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RECEIVED

TRANS IN

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

RETD/TRANS OUT

Select this box if
Form G-28 is
attached.

COMPLETED

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

The individual applying for relief under former Immigration and Nationality Act (INA) section 212(c) completes this section.
1.

Your Full Legal Name

Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

Other Names Used

Provide any other names you have used at any time since birth, including aliases, maiden names, and nicknames. If you need
extra space to complete this section, use the space provided in Part 12. Additional Information.
Family Name (Last Name)

3.

Given Name (First Name)

Middle Name

Current Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

4.

Postal Code

ZIP Code

Country

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

Yes

No

NOTE: If you answered "No" to Item Number 4., provide your physical address below.

Form I-191 Edition 07/20/21

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Part 1. Information About You (continued)
5.

Current Physical Address (if different from the address above)
In Care Of Name (if any)

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Other Information
6.

Date of Birth (mm/dd/yyyy)

7.

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

8.

USCIS Online Account Number (if any)
►

9.

Your Country of Citizenship or Nationality

List the country where you are currently a citizen or national. If you need extra space to complete this item, use the space
provided in Part 12. Additional Information.
10. Place of Birth
List the city/town/village, state/ province, and country where you were born.
City/Town/Village of Birth

State/Province of Birth

Country of Birth

11. Information About Your Lawful Permanent Resident (LPR) Status
A. Date You Obtained Your LPR Status (mm/dd/yyyy)
B. How You Obtained Your LPR Status (select only one box)
Admission with an Immigrant Visa at a Port of Entry (Complete Item Number 12.)
Adjustment of Status Granted by USCIS While in the United States (Complete Item Number 13.)
Adjustment of Status Granted by Immigration Judge or Board of Immigration Appeals While Inside the United States
(Complete Item Number 14.)
12. If you selected “Admission with an Immigrant Visa at a Port of Entry,” provide the information requested below.
Port-of-Entry City or Town

Port-of-Entry State

Means of Transportation

Form I-191 Edition 07/20/21

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Part 1. Information About You (continued)
13. If you selected “Adjustment of Status Granted by USCIS While in the United States,” provide the USCIS Office location that
granted your adjustment of status application below.

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USCIS Office Location

14. If you selected “Adjustment of Status by Immigration Judge or Board of Immigration Appeals While inside the United States”
provide the date your status was granted and the location of the Immigration Judge below.
Date Adjustment of Status was Granted

Location of Immigration Judge

(mm/dd/yyyy)

Information About Your Last Arrival in the United States
15. Passport or Travel Document Number

16. Country That Issued Your Passport or Travel Document

17. Expiration Date for Your Passport or Travel Document
(mm/dd/yyyy)

18. Date of Your Last Arrival into United States, On or About
(mm/dd/yyyy)

Information About Your Travels From and To the United States

Provide the information requested below about your travels from and to the United States since you were admitted as, or adjusted your
status to, an LPR. If you need extra space to complete this section, use the space provided in Part 12. Additional Information.
19. Trip 1

City of Departure

State of Departure

Date of Departure (mm/dd/yyyy)

State of Arrival

Date of Arrival (mm/dd/yyyy)

Means of Transportation for Departure

City of Arrival

Means of Transportation for Arrival

Purpose of Trip

Is this information approximate?

Form I-191 Edition 07/20/21

Yes

No

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Part 1. Information About You (continued)
20. Trip 2
City of Departure

State of Departure

Date of Departure (mm/dd/yyyy)

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Means of Transportation for Departure

City of Arrival

State of Arrival

Date of Arrival (mm/dd/yyyy)

Means of Transportation for Arrival

Purpose of Trip

Is this information approximate?
21. Trip 3

Yes

No

City of Departure

State of Departure

Date of Departure (mm/dd/yyyy)

State of Arrival

Date of Arrival (mm/dd/yyyy)

Means of Transportation for Departure

City of Arrival

Means of Transportation for Arrival

Purpose of Trip

Is this information approximate?

Yes

No

Part 2. Biographic Information
1.

Ethnicity (Select only one box)
Hispanic or Latino

2.

Not Hispanic or Latino

Race (Select all applicable boxes)
White

Asian

Black or African
American

3.

Height

Feet

4.

Weight

Pounds

5.

Eye Color (Select only one box)
Black

6.

American Indian or
Alaska Native

Native Hawaiian or
Other Pacific Islander

Inches

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other

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

Black

Form I-191 Edition 07/20/21

Blond

Brown

Gray

Red

Sandy

White

Unknown/
Other
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Part 3. Information About Your Criminal Convictions
The information requested below relates to your criminal convictions for which you are seeking relief under former INA section 212(c).
1.

Conviction 1

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A. Date (mm/dd/yyyy)

B. Name of Court

C. Town or City of Court

State of Court

D. Court Case Number
E. Conviction Entered

After Trial

Based on Guilty or No Contest Plea

If you selected “Based on Guilty or No Contest Plea,” provide the
date the plea was entered (mm/dd/yyyy)

F. Specific Offense as Stated in the Judgment of Conviction

NOTE: If the conviction is related to more than one offense, provide the name of each specific offense.
G. Citation to Federal, State, or Local Law, as Stated in the Judgment of Conviction

NOTE: If the conviction is related to more than one citation, provide each separate citation.
H. Sentence, Probation, or Other Punishment Imposed

2.

Imprisonment Served From

Imprisonment Served To

(mm/dd/yyyy)

(mm/dd/yyyy)

Conviction 2
A. Date (mm/dd/yyyy)

B. Name of Court

C. Town or City of Court

State of Court

D. Court Case Number
E. Conviction Entered

After Trial

Based on Guilty or No Contest Plea

If you selected “Based on Guilty or No Contest Plea,” provide the
date the plea was entered (mm/dd/yyyy)
F. Specific Offense as Stated in the Judgment of Conviction

NOTE: If the conviction is related to more than one offense, provide the name of each specific offense.
G. Citation to Federal, State, or Local Law, as Stated in the Judgment of Conviction

NOTE: If the conviction is related to more than one citation, provide each separate citation.

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Part 3. Information About Your Criminal Convictions (continued)
H. Sentence, Probation, or Other Punishment Imposed

3.

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Imprisonment Served From

Imprisonment Served To

(mm/dd/yyyy)

(mm/dd/yyyy)

Conviction 3

A. Date (mm/dd/yyyy)

B. Name of Court

C. Town or City of Court

State of Court

D. Court Case Number
E. Conviction Entered

After Trial

Based on Guilty or No Contest Plea

If you selected “Based on Guilty or No Contest Plea,” provide the
date the plea was entered (mm/dd/yyyy)

F. Specific Offense as Stated in the Judgment of Conviction

NOTE: If the conviction is related to more than one offense, provide the name of each specific offense.
G. Citation to Federal, State, or Local Law, as Stated in the Judgment of Conviction

NOTE: If the conviction is related to more than one citation, provide each separate citation.
H. Sentence, Probation, or Other Punishment Imposed

Imprisonment Served From

Imprisonment Served To

(mm/dd/yyyy)

(mm/dd/yyyy)

NOTE: If you have more than three convictions (including conviction after trial, guilty pleas, and no contest pleas), use the space
provided in Part 12. Additional Information to provide the requested information about each additional conviction.

Form I-191 Edition 07/20/21

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Part 4. Information About Your Residences
Provide the following information about where you have lived during the last seven years. List your most recent residence first and
then every residence where you have lived during the last seven years. You should not have any gaps in time. If you need extra space
to complete this section, use the space provided in Part 12. Additional Information.
1.

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Physical Address 1

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

Resided From (mm/dd/yyyy)
2.

Resided To (mm/dd/yyyy)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Postal Code

Resided From (mm/dd/yyyy)

ZIP Code

Country

Resided To (mm/dd/yyyy)

Physical Address 3

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

Resided From (mm/dd/yyyy)
4.

Country

Physical Address 2

Province

3.

ZIP Code

ZIP Code

Country

Resided To (mm/dd/yyyy)

Physical Address 4
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Resided From (mm/dd/yyyy)

Form I-191 Edition 07/20/21

Postal Code

ZIP Code

Country

Resided To (mm/dd/yyyy)

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Part 5. Information About Your Employment
Provide the following information about where you have worked full-time or part-time during the last seven years. List your most
recent employer first and then list every other employer where you worked at any time during the last seven years. If you were
unemployed, type or print “Unemployed” in the “Name of Employer” field and provide applicable information. If you need extra
space to complete this section, use the space provided in Part 12. Additional Information.
1.

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Employer 1

Name of Employer

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Employed To (mm/dd/yyyy)

Employed From (mm/dd/yyyy)
Your Occupation
2.

Employer 2

Name of Employer

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Employed From (mm/dd/yyyy)

Postal Code

ZIP Code

Country

Employed To (mm/dd/yyyy)

Your Occupation

Form I-191 Edition 07/20/21

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Part 5. Information About Your Employment (continued)
3.

Employer 3
Name of Employer

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Employed To (mm/dd/yyyy)

Employed From (mm/dd/yyyy)
Your Occupation
4.

Employer 4

Name of Employer

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Employed To (mm/dd/yyyy)

Employed From (mm/dd/yyyy)
Your Occupation

Part 6. Information About Your Family
Provide the following information about your spouse, all children, and your parents. If you need extra space to complete this section,
use the space provided in Part 12. Additional Information.

Spouse's Information
1.

Spouse's Current Legal Name
Family Name (Last Name)

Given Name (First Name)

2.

A-Number
► A-

3.

USCIS Online Account Number
►

5.

Date of Birth (mm/dd/yyyy)

6.

Country of Birth

Form I-191 Edition 07/20/21

Middle Name

4.

Spouse's Gender
Male
Female

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Part 6. Information About Your Family (continued)
7.

Country of Citizenship or Nationality

8.

Spouse's Physical Address

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Same as applicant's

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Information for Child 1
9.

Current Legal Name of Child 1
Family Name (Last Name)

10. A-Number
► A-

13. Date of Birth (mm/dd/yyyy)

Given Name (First Name)

Middle Name

11. USCIS Online Account Number
►

12. Child's Gender
Male
Female

14. Country of Birth

15. Country of Citizenship or Nationality

16. Physical Address of Child 1
Same as applicant's
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Information for Child 2
17. Current Legal Name of Child 2
Family Name (Last Name)

18. A-Number
► A21. Date of Birth (mm/dd/yyyy)

Form I-191 Edition 07/20/21

Given Name (First Name)

19. USCIS Online Account Number
►

Middle Name

20. Child's Gender
Male
Female

22. Country of Birth

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Part 6. Information About Your Family (continued)
23. Country of Citizenship or Nationality

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24. Physical Address of Child 2
Same as applicant's

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Information for Child 3

25. Current Legal Name of Child 3
Family Name (Last Name)

26. A-Number
► A-

29. Date of Birth (mm/dd/yyyy)

Given Name (First Name)

Middle Name

27. USCIS Online Account Number
►

28. Child's Gender
Male
Female

30. Country of Birth

31. Country of Citizenship or Nationality

32. Physical Address of Child 3
Same as applicant's
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Information for Child 4
33. Current Legal Name of Child 4
Family Name (Last Name)

Given Name (First Name)

34. A-Number
► A-

35. USCIS Online Account Number
►

37. Date of Birth (mm/dd/yyyy)

38. Country of Birth

Form I-191 Edition 07/20/21

Middle Name

36. Child's Gender
Male
Female

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Part 6. Information About Your Family (continued)
39. Country of Citizenship or Nationality

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40. Physical Address of Child 4
Same as applicant's

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Information About Your Parents

Information for Parent 1

41. Current Legal Name of Parent 1
Family Name (Last Name)

42. A-Number
► A-

45. Date of Birth (mm/dd/yyyy)

Given Name (First Name)

Middle Name

43. USCIS Online Account Number
►

44. Gender
Male

Female

46. Country of Birth

47. Country of Citizenship or Nationality

48. Physical Address of Parent 1
Same as applicant's
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Information for Parent 2
49. Current Legal Name of Parent 2
Family Name (Last Name)

50. A-Number
► A-

Form I-191 Edition 07/20/21

Given Name (First Name)

51. USCIS Online Account Number
►

Middle Name

52. Gender
Male

Female

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Part 6. Information About Your Family (continued)
53. Date of Birth (mm/dd/yyyy)

54. Country of Birth

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55. Country of Citizenship or Nationality

56. Physical Address of Parent 2
Same as applicant's

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Part 7. Other Grounds for Removal

NOTE: If you need extra space to complete this section, use the space provided in Part 12. Additional Information.
1.

Provide an explanation in the space provided why you may be subject to removal on any grounds besides the criminal convictions
listed in Part 3. Information About Your Criminal Convictions. The other grounds of removal may include any
inadmissibility grounds in INA section 212(a) or any deportability grounds in INA section 237(a).

2.

In addition to the criminal convictions listed in Part 3., list and provide a full explanation of any other time you committed, or
were accused of committing, a criminal offense inside or outside of the United States, as well as any other time you were arrested,
cited, detained, charged, investigated, received deferred adjudication of guilt, withholding of adjudication of guilt, or pretrial
diversion, or plead guilty to or were convicted of a criminal offense inside or outside of the United States.
NOTE: If you were ever arrested, detained, or investigated by any law enforcement officer for any reason, and no charges were
filed, include an original official statement by the arresting or detaining agency or applicable court order confirming that no
charges were filed. If you were ever arrested, detained, or investigated by any law enforcement officer for any reason and charges
were filed, or if charges were filed against you without an arrest, submit an original or court-certified copy of the complete arrest
record and/or disposition for each incident (for example, a dismissal order or an acquittal order).

Form I-191 Edition 07/20/21

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Part 8. Discretion
1.

In the space provided below, explain why U.S. Citizenship and Immigration Services (USCIS) or the immigration judge should
approve your Form I-191 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-191 Instructions. If you need extra space to complete your statement, use the
space provided in Part 12. Additional Information.

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NOTE: You may provide your explanation on a separate sheet of paper. If you use a separate sheet, select the box below and
include that sheet with your Form I-191. You must submit your explanation at the same time as your Form I-191.

2.

I provided my explanation on a separate sheet and included that sheet with this Form I-191.

Part 9. Applicant's Contact Information, Certification, and Signature
Applicant's Contact Information

Provide your daytime telephone number, mobile telephone number (if any), and email address (if any)
1.

Applicant's Daytime Telephone Number

3.

Applicant's Email Address (if any)

2.

Applicant's Mobile Telephone Number (if any)

Applicant's Certification and Signature
I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
my application, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 10.,
understood, all of the responses and information contained in, and submitted with, my application, and that all of the responses and the
information are complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records
that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
4.

Applicant's Signature

Form I-191 Edition 07/20/21

Date of Signature (mm/dd/yyyy)

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Part 10. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

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Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification and Signature

I certify, under penalty of perjury, that I am fluent in English and
,
and I have interpreted every question on the application and Instructions and interpreted the applicant's answers to the questions in that
language, and the applicant informed me that they understood every instruction, question, and answer on the application.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 11. Contact Information, Declaration, and Signature of the Person Preparing This Application, if
Other Than the Applicant
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

Form I-191 Edition 07/20/21

4.

Preparer's Mobile Telephone Number (if any)

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Part 11. Contact Information, Declaration, and Signature of the Person Preparing This Application, if
Other Than the Applicant (continued)
Preparer's Certification and Signature

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I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express consent and that
all of the responses and information contained in and submitted with the application are complete, true, and correct and reflects only
information provided by the applicant. The applicant reviewed the responses and information and informed me that they understand
the responses and information in or submitted with the application.
6.

Preparer's Signature

Form I-191 Edition 07/20/21

Date of Signature (mm/dd/yyyy)

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Part 12. 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.

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1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

A. Page Number

D.

5.

A. Page Number

D.

6.

A. Page Number

Given Name (First Name)

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

Middle Name

D.

7.

A. Page Number

D.

NOTE TO ALL APPLICANTS: Do not complete Part 13. USCIS will complete this section.

Form I-191 Edition 07/20/21

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Part 13. USCIS Decision (For Official Use Only)
1.

This application is:
Granted

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Denied
2.

Terms and Conditions

3.

Date of Action (mm/dd/yyyy)

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