I-191 Form Table of Changes

TABLE OF CHANGES – FORM

Form I-191, Application for Relief Under Former Section 212(c) of the Immigration and Nationality Act (INA)

OMB Number: 1615-0016

06/27/2023

Reason for Revision: Limited REV

Project Phase: OMBReview

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Edition Date 07/20/2021

Expires 11/30/2023

Current Page Number and Section	Current Text	Proposed Text
Pages 9-13, Part 6. Information About Your Family	[Page 9] 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. [new] 1. Spouse's Current Legal Name Family Name (Last Name) Given Name (First Name) Middle Name Spouse’s Other Information 2. A-Number 3. USCIS Online Account Number 4. Spouse’s Gender Male Female 5. Date of Birth (mm/dd/yyyy) 6. Country of Birth [Page 10] 7. Country of Citizenship or Nationality 8. Spouse's Physical Address [] Same as applicant’s Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country [new] 9. Current Legal Name of Child 1 Family Name (Last Name) Given Name (First Name) Middle Name Other Information for Child 1 10. A-Number 11. USCIS Online Account Number 12. Child’s Gender Male Female 13. Date of Birth (mm/dd/yyyy) 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 ZIP Code Province Postal Code Country [new] 17. Current Legal Name of Child 2 Family Name (Last Name) Given Name (First Name) Middle Name Other Information for Child 2 18. A-Number 19. USCIS Online Account Number 20. Child’s Gender Male Female 21. Date of Birth (mm/dd/yyyy) 22. Country of Birth [Page 11] 23. Country of Citizenship or Nationality 24. Physical Address of Child 2 [] Same as applicant’s Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country [new] 25. Current Legal Name of Child 3 Family Name (Last Name) Given Name (First Name) Middle Name Other Information for Child 3 26. A-Number 27. USCIS Online Account Number 28. Child’s Gender Male Female 29. Date of Birth (mm/dd/yyyy) 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 ZIP Code Province Postal Code Country [new] 33. Current Legal Name of Child 4 Family Name (Last Name) Given Name (First Name) Middle Name Other Information for Child 4 34. A-Number 35. USCIS Online Account Number 36. Child’s Gender Male Female 37. Date of Birth (mm/dd/yyyy) 38. Country of Birth [Page 12] 39. Country of Citizenship or Nationality 40. Physical Address of Child 4 [] Same as applicant’s Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Information About Your Parents [new] 41. Current Legal Name of Parent 1 Family Name (Last Name) Given Name (First Name) Middle Name Other Information for Parent 1 42. A-Number 43. USCIS Online Account Number 44. Gender Male Female 45. Date of Birth (mm/dd/yyyy) 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 ZIP Code Province Postal Code Country [new] 49. Current Legal Name of Parent 2 Family Name (Last Name) Given Name (First Name) Middle Name Other Information for Parent 2 50. A-Number 51. USCIS Online Account Number 52. Gender Male Female [Page 13] 53. Date of Birth (mm/dd/yyyy) 54. Country of Birth 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 ZIP Code Province Postal Code Country	[Page 9] 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) Middle Name [deleted] 2. A-Number 3. USCIS Online Account Number 4. Spouse’s Gender Male Female 5. Date of Birth (mm/dd/yyyy) 6. Country of Birth [Page 10] 7. Country of Citizenship or Nationality 8. Spouse's Physical Address [] Same as applicant’s Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Information for Child 1 9. Current Legal Name of Child 1 Family Name (Last Name) Given Name (First Name) Middle Name [deleted] 10. A-Number 11. USCIS Online Account Number 12. Child’s Gender Male Female 13. Date of Birth (mm/dd/yyyy) 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 ZIP Code Province Postal Code Country Information for Child 2 17. Current Legal Name of Child 2 Family Name (Last Name) Given Name (First Name) Middle Name [deleted] 18. A-Number 19. USCIS Online Account Number 20. Child’s Gender Male Female 21. Date of Birth (mm/dd/yyyy) 22. Country of Birth [Page 11] 23. Country of Citizenship or Nationality 24. Physical Address of Child 2 [] Same as applicant’s Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Information for Child 3 25. Current Legal Name of Child 3 Family Name (Last Name) Given Name (First Name) Middle Name [deleted] 26. A-Number 27. USCIS Online Account Number 28. Child’s Gender Male Female 29. Date of Birth (mm/dd/yyyy) 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 ZIP Code Province Postal Code Country Information for Child 4 33. Current Legal Name of Child 4 Family Name (Last Name) Given Name (First Name) Middle Name [deleted] 34. A-Number 35. USCIS Online Account Number 36. Child’s Gender Male Female 37. Date of Birth (mm/dd/yyyy) 38. Country of Birth [Page 12] 39. Country of Citizenship or Nationality 40. Physical Address of Child 4 [] Same as applicant’s Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Information About Your Parents Information for Parent 1 41. Current Legal Name of Parent 1 Family Name (Last Name) Given Name (First Name) Middle Name [deleted] 42. A-Number 43. USCIS Online Account Number 44. Gender Male Female 45. Date of Birth (mm/dd/yyyy) 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 ZIP Code Province Postal Code Country Information for Parent 2 49. Current Legal Name of Parent 2 Family Name (Last Name) Given Name (First Name) Middle Name [deleted] 50. A-Number 51. USCIS Online Account Number 52. Gender Male Female [Page 13] 53. Date of Birth (mm/dd/yyyy) 54. Country of Birth 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 ZIP Code Province Postal Code Country
Pages 14-15, Part 9. Applicant’s Statement, Contact Information, Certification, and Signature	[Page 14] Part 9. Applicant’s Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-191 Instructions before completing this section. Applicant’s Statement NOTE: Select the box for either Item Number A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter 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. B. The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part 11., [Fillable field], prepared this application for me based only upon information I provided or authorized. Applicant’s Contact Information [new] 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) [Page 15] Applicant’s 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 law. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and provided or authorized all of the information in my application; 2) I understood all of the information contained in, and submitted with, my application; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I 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 6. Applicant’s Signature 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 or the immigration judge may deny your application.	[Page 14] Part 9. Applicant’s Contact Information, Certification, and Signature [deleted] 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 2. Applicant’s Mobile Telephone Number (if any) 3. Applicant’s Email Address (if any) Applicant’s Certification and Signature [deleted] 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. [deleted] 4. Applicant’s Signature Date of Signature (mm/dd/yyyy) [deleted]
Pages 15-16, Part 10. Interpreter’s Contact Information, Certification, and Signature	[Page 15] Part 10. Interpreter’s Contact Information, Certification, and Signature If you used an interpreter (as indicated in Part 9. Item B. in Item Number 1.), you must provide the following information about the interpreter. The interpreter must sign the Interpreter’s Certification below. Interpreter’s Full Name 1. Interpreter’s Family Name (Last Name) Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name (if any) Interpreter’s Mailing Address 3. Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country [Page 16] 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) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part 9., Item B., in Item Number 1., 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 Certification, and has verified the accuracy of every answer. Interpreter’s Signature 7. Interpreter’s Signature Date of Signature (mm/dd/yyyy)	[Page 15] Part 10. Interpreter’s Contact Information, Certification, and Signature [deleted] Interpreter’s Full Name 1. Interpreter’s Family Name (Last Name) Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name [deleted] Interpreter’s Contact Information 3. Interpreter’s Daytime Telephone Number 4. Interpreter’s Mobile Telephone Number (if any) 5. Interpreter’s Email Address (if any) Interpreter’s Certification and Signature I certify, under penalty of perjury, that I am fluent in English and [Fillable language field], 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. [deleted] 6. Interpreter’s Signature Date of Signature (mm/dd/yyyy)
Pages 16-17, Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 16] Part 11. 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. Preparer’s Family Name (Last Name) Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3. Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country [Page 17] 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) 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. 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. 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 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. Preparer’s Signature Date of Signature (mm/dd/yyyy)	[Page 16] Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant [deleted] Preparer’s Full Name 1. Preparer’s Family Name (Last Name) Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name [deleted] Preparer’s Contact Information 3. Preparer’s Daytime Telephone Number 4. Preparer’s Mobile Telephone Number (if any) 5. Preparer’s Email Address (if any) [deleted] Preparer’s Certification and Signature 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. [deleted] 6. Preparer’s Signature Date of Signature (mm/dd/yyyy)

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