Information Collection

Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)

IC 6595 under ICR 202507-0920-015 · OMB 0920-0006.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4.422-1 Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form and Instruction
Form 4.422-1 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form and Instruction
Form 0920-0006 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADMISSIBILITY - Revised 21JUL2025 Application for Waiver of Inadmissibility Under Immigration and Nationality Act (Form 4-422-1)	Form and Instruction
4.422-1 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADM Attachment C CDC Form 4.422-1.pdf	Form and Instruction
4.422-1 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADM Attachment C CDC Form 4.422-1.pdf	Form and Instruction
0920-0006 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADM 4.422 Form_July 2025 Clean.docx	Form and Instruction
0920-0006 STATEMENTS IN SUPPORT OF APPLICATION FOR WAIVER OF INADM 4.422 Form_July 2025 Clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-0006

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4.422-1				Yes	No	Fillable Printable
Form and Instruction	0920-0006			N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-02-0102: Alien Mental Waiver Program

FR Citation: 51 FR 42461

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	3,260	3,260

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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