Form I-690 Application for Waiver of Grounds of Inadmissibility Und

Application for Waiver of Grounds of Inadmissibility Under
Sections 245A or 210 of the Immigration and Nationality Act
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-690
OMB No. 1615-0032
Expires 12/31/2023

For Government Use Only

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PRODUCTION
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Alien Registration Number (A-Number of This Applicant):
A-

Action Block

Fee Receipt Number (This application):

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

Attorney State Bar Number
(if applicable)

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

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Read the Instructions before completing this application.

Part 1. Information About You (Applicant)
Your Current Legal Name
1.

Family Name (Last Name)

Given Name (First Name)

Mailing Address
2.

(USPS ZIP Code Lookup)

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

3.

Middle Name (if applicable)

Postal Code

ZIP Code

Country

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

Yes

No

If you answered "No" to Item Number 3., provide your physical address in Item Number 4.

Form I-690 Edition 12/02/21

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Part 1. Information About You (Applicant) (continued)
Physical Address
4.

Street Number and Name

Apt. Ste. Flr. Number

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City or Town

Province

State

Postal Code

ZIP Code

Country

Other Information
5.

City/Town/Village of Birth

7.

Date of Birth (mm/dd/yyyy)

6.

8.

Country of Birth

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

9.

USCIS Online Account Number (if any)
►

10.

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

Part 2. Additional Information About You
1.

I am applying for a waiver for this primary application:

Permanent Residence (Form I-698, LIFE Act Form I-485)
2.

4.

Date You Filed the Primary Application
(mm/dd/yyyy)

3.

Temporary Residence (Form I-687 or Form I-700)

Receipt Number for Primary Application
►

I am applying for a waiver of (select all applicable boxes):

INA section (Please see the Instructions for more information on these sections.)

5.

212 (a)(1)(A)(i)

212(a)(2)(I)

212(a)(8)(A)

212 (a)(10)(B)

212 (a)(1)(A)(ii)

212(a)(4)

212(a)(8)(B)

212 (a)(10)(C)

212 (a)(1)(A)(iii)

212(a)(6)(B)

212(a)(9)(A)(i)

212 (a)(10)(D)

212 (a)(1)(A)(iv)

212(a)(6)(C)(i)

212(a)(9)(A)(ii)

212 (a)(10)(E)

212 (a)(2)(A)(i)(II)

212(a)(6)(C) (ii)

212(a)(9)(B)(i)(I)

Other Inadmissibility - Specify below

212(a)(2)(D)

212(a)(6)(D)

212(a)(9)(B)(i)(II)

212(a)(2)(E)

212(a)(6)(E)

212(a)(9)(C)(i)(I)

212(a)(2)(G)

212(a)(6)(F)

212(a)(9)(C)(i)(II)

212(a)(2)(H)

212(a)(6)(G)

212 (a)(10)(A)

List the specific reasons why you are inadmissible in the space below.

Form I-690 Edition 12/02/21

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Part 2. Additional Information About You (continued)
6.

List all immediate relatives in the United States (parents, spouse, and children). If you need extra space to complete this section,
use the space provided in Part 6. Additional Information.
A. Relative 1
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy)

Relationship

ZIP Code

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

B. Relative 2

Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy)

Relationship

ZIP Code

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

C. Relative 3
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy)

Relationship

ZIP Code

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

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Part 2. Additional Information About You (continued)
D. Relative 4
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Date of Birth (mm/dd/yyyy)

Relationship

ZIP Code

A-Number (if any)
► A-

Immigration Status (for example, U.S. citizen, lawful permanent resident, valid
nonimmigrant status, deferred action recipient)

7.

Describe the family unity, humanitarian, or public interest reasons or considerations for why U.S. Citizenship and Immigration
Services (USCIS) should grant your waiver. If you need extra space to complete this section, use the space provided in Part 6.
Additional Information.

Part 3. 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 4.,
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-690 Edition 12/02/21

Date of Signature (mm/dd/yyyy)

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Part 4. 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

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 5. 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-690 Edition 12/02/21

4.

Preparer's Mobile Telephone Number (if any)

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Part 5. 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-690 Edition 12/02/21

Date of Signature (mm/dd/yyyy)

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Part 6. 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.

D.

4.

A.

D.

5.

A.

D.

6.

A.

Given Name (First Name)

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Middle Name

D.

7.

A.

D.

Form I-690 Edition 12/02/21

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