Fillable Form I-601: Application for Waiver of Grounds of (American Immigration Lawyers Association)

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Form I-601: Application for Waiver of Grounds of (American Immigration Lawyers Association)

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Page 1 of 12Form I-601 12/02/19
To be completed
by an Attorney
or Accredited
Representative (if any).
Select this box if
Form G-28 is
attached or G-28I
is attached.
Inadmissible Under
Benefits Category
For
USCIS
Use
Only
Application for Waiver of Grounds of Inadmissibility
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-601
OMB No. 1615-0029
Expires 07/31/2021
Fee Stamp
Initial
Receipt
Resubmitted Action Block
Relocated
Received Sent
Part 1. Information About You
Your Full Name
3.a.
4.c.
4.b.
4.a.
Family Name
(Last Name)
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.
List all other names you have ever used, including maiden names,
aliases, and nicknames. If you need extra space to complete this
section, use the space provided in Part 10. Additional
Information.
Middle Name
Alien Registration Number (A-Number) (if any)1.
►
A-
USCIS Online Account Number (if any)2.
►
Other Names Used
Mailing Address
NOTE: If you are outside of the United States, provide a U.S.
mailing address if available. If a U.S. mailing address is not
available, provide your mailing address outside the United States.
If you answered "No" to Item Number 6., provide your
physical address in Item Numbers 7.a. - 7.h.
6. Is your current physical address the same as your mailing
address?
Yes No
5.a. In Care Of Name
Street Number
and Name
5.b.
5.c.
Apt.
Flr.Ste.
5.d. City or Town
5.g. Province
5.i. Country
5.e.
State
5.f.
ZIP Code
5.h.
Postal Code
START HERE - Type or print in black ink.►
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
Immigrant Adjustment of Status TPS
V Nonimmigrant K Nonimmigrant
212(a)(1)
212(a)(2)
212(a)(3)
212(a)(4)
212(a)(6)
212(a)(9)
212(a)(10)
Other
(USPS ZIP Code Lookup)
Page 2 of 12Form I-601 12/02/19
Have you previously filed Form I-212, Application for
Permission to Reapply for Admission into the United
States After Deportation or Removal?
18.b. If you answered "Yes" to Item Number 18.a., provide
the USCIS Receipt Number for your Form I-212, if any.
Part 1. Information About You (continued)
Are you filing this application after you have already filed
Form I-485, Application to Register Permanent Residence
or Adjust Status?
17.a. Are you filing this application after you have already filed
Form I-821, Application for Temporary Protected Status?
16.b. If you answered "Yes" to Item Number 16.a., provide
the USCIS Receipt Number for your Form I-485.
16.a.
No
Yes No
Yes
►
►
►
Yes
No
18.a.
18.c. Where did you file your application (for example, USCIS
Office, U.S. Port-of-Entry, Immigration Court)?
If you answered "Yes" to Item Number 17.a., provide
the USCIS Receipt Number for your Form I-821, if any.
17.b.
Are you submitting Form I-212 along with this application?
19.
NoYes
18.d. Date Filed (mm/dd/yyyy)
Other Information
U.S. Social Security Number (if any)8.
►
Date of Birth (mm/dd/yyyy)
10.
Gender Male Female
11. City or Town
of Birth
12. Province
of Birth (if applicable)
13.
Country of Birth
Physical Address
9.
14. Country of Citizenship or Nationality
If you seek a visa and you were already interviewed by a U.S.
Department of State (DOS) consular officer at a U.S. Embassy
or U.S. Consulate, provide the information requested in Item
Numbers 15.a. - 15.b.
15.a.
DOS Consular Case Number (if available)
Part 2. U.S. Entry Information
Provide information for your previous periods of stay in the
United States, beginning with your most recent arrival date.
NOTE: If you need extra space to complete this section, use
the space provided in Part 10. Additional Information.
1.a. Date You Entered the U.S. (mm/dd/yyyy)
7.g. Postal Code
7.h. Country
7.d. State 7.e. ZIP Code
7.c. City or Town
Street Number
and Name
7.a.
7.b.
Apt.
Flr.Ste.
7.f. Province
The location of the U.S. Embassy or U.S. Consulate where
your visa application is being or will be made
15.b.
1.b.
Location at Which You Entered the U.S.
1.d. U.S. City or Town Where You Lived
1.c.
Immigration Status At the Time of Your Entry Into the U.S.
2.a. Date You Entered the U.S. (mm/dd/yyyy)
City
Country
Page 3 of 12Form I-601 12/02/19
Part 2. U.S. Entry Information (continued)
Location at Which You Entered the U.S.
2.e. U.S. City or Town Where You Lived
2.d
If you are seeking a waiver of inadmissibility because you have
a Class A Tuberculosis condition (as defined by U.S.
Department of Health and Human Services (HHS) regulations),
you must complete Part 11. of this application.
If you are seeking a waiver of inadmissibility because you have
a history of physical or mental disorders, you must attach the
information requested in the instructions.
I am an applicant for an immigrant visa or adjustment of
status (other than based on T nonimmigrant status or based
on classification as a Special Immigrant Juvenile, see Section
B below), or for K or V nonimmigrant status, and I believe
or I was told that I am inadmissible because (review Form
I-601 Instructions for a detailed explanation of the individual
grounds of inadmissibility listed below):
Section A
Select all grounds that you believe apply to you.
I have a communicable disease of public health
significance. (A list of communicable diseases of
public health significance can be found in the Specific
Instructions section of Form I-601 Instructions.)
1.
2.
I seek an exemption from the vaccination requirement
because vaccinations are against my religious beliefs
or moral convictions.
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.
3.
4. I have been involved in a crime of moral turpitude
(other than a purely political offense).
Part 3. Biographic Information (for USCIS
Applicant only)
1.
2.
Hair Color (Select only one box) 6.
Height
4. Weight
Feet Inches
3.
Pounds
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select only one box)
Race (Select all applicable boxes)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Asian
Black or African American
Black Brown
Green
Maroon
Pink
HazelGray
Blue
5. Eye Color (Select only one box)
Unknown/Other
Black
Brown Red
White
Unknown/
Other
Sandy
Gray
BlondBald (No hair)
2.c. Immigration Status At the Time of Your Reentry Into the U.S.
Part 4. Reasons for Inadmissibility
Select all of the following grounds that you believe, according to
the best of your knowledge, or that you were told, apply to you.
Only select the applicable grounds listed under the immigration
benefit you are seeking.
If you were ever arrested or convicted, provide the disposition
(outcome) for all arrests or convictions (for example, dismissed
from the appropriate authority). You also will be required to
provide certified court records or dispositions for all convictions.
5.
I have been involved in a controlled substance
violation according to the laws and regulations of any
state, the United States, or a foreign country related
to a single offense of simple possession of 30 grams
or less of marijuana.
6. 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.
7.
I am coming to the U.S. to engage in prostitution or,
in the past 10 years, I have engaged in prostitution
(including receiving the proceeds of, in full or in
part), procurement of prostitution, or I continue to
engage in prostitution or procurement of prostitution.
In the past 10 years, I have (either directly or
indirectly) procured, attempted to procure, or to
import prostitutes or persons for the purpose of
prostitution.
8.
2.b. Date You Departed the U.S. (mm/dd/yyyy)
Page 4 of 12Form I-601 12/02/19
Part 4. Reasons for Inadmissibility (continued)
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.
11.
I have sought to procure an immigration benefit by
fraud or by concealing or misrepresenting a material
fact (immigration fraud or misrepresentation.)
12.
I was previously removed from the United States.
(See instructions for Nicaraguan Adjustment and
Central American Relief Act (NACARA) and Haitian
Refugee Immigration Fairness Act (HRIFA) applicants
only. All other applicants file Form I-212.)
16.
I am subject to the 3-year or the 10-year bar to
admissibility because I was previously unlawfully
present in the United States in excess of either 180
days or one year or more, respectively, and
subsequently departed the United States.
15.
I am subject to a civil penalty because I was the
subject of a final order for violation of the
Immigration and Nationality Act (INA) section 274C.
14.
I have been engaged in alien smuggling.13.
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 instructions for NACARA, HRIFA,
and the instructions for approved Violence Against
Women Act (VAWA) self-petitioners only. Other
applicants file Form I-212.)
17.
Other (specify):18.
I am applying for TPS and I believe or I was told that I am
inadmissible because:
20. I have a communicable disease of public health
significance. (A list of communicable diseases of
public health significance can be found in the Specific
Instructions section of Form I-601 Instructions.)
Select all grounds that you believe, according to the best of your
knowledge, or that you were told apply to you.
Section C
21. I have or had a physical or mental disorder and
behavior (or a 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.
22.
I am or have been a drug abuser or drug addict as
described in U.S. Department of Health and Human
Services (HHS) Regulations. See 42 CFR 34.
24. I am coming to the U.S. to engage in prostitution or,
in the past 10 years, I have engaged in prostitution
(including receiving the proceeds of, in full or in
part,) procurement of prostitution, or I continue to
engage in prostitution or procurement of prostitution.
23.
I have been involved in a controlled substance
violation according to the laws and regulations of any
state, the United States, or a foreign country related
to a single offense of simple possession of 30 grams
or less of marijuana.
I came to the United States or I am coming to the
United States to engage in any other unlawful
commercialized vice, whether or not it is related to
prostitution.
26.
25.
In the past 10 years, I have (either directly or indirectly,)
procured, attempted to procure, or to import prostitutes
or persons for the purpose of prostitution.
I have been involved in serious criminal activity and
have asserted immunity from prosecution.
27.
I have been involved in serious criminal activity and
have asserted immunity from prosecution.
10.
I came to the United States or I am coming to the
United States to engage in any other unlawful
commercialized vice whether or not it is related to
prostitution.
9.
Specify (Review Form I-601 Instructions for a
detailed explanation of the individual grounds of
inadmissibility related to your Form I-601.)
19.
I am applying for adjustment of status based on a valid T
nonimmigrant status or based on classification as a Special
Immigrant Juvenile and I believe or I was told that I am
inadmissible because:
Section B
I did not attend or did not remain at a removal
proceeding to determine my inadmissibility or
deportability.
28.
Page 5 of 12Form I-601 12/02/19
Part 4. Reasons for Inadmissibility (continued)
40.
33. I am ineligible for U.S. citizenship because 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.
I have practiced polygamy since I entered the United
States or I intend to practice polygamy in the United
States.
34.
I am accompanying another alien who is inadmissible
after being certified to be helpless under INA section
232(c) and I am inadmissible because that other alien
requires my protection or guardianship.
35.
I have detained, retained, or withheld the custody of a
child having a lawful claim to U.S. citizenship, outside
the United States, from a person granted custody.
36.
I was an unlawful voter who voted in violation of a
Federal, state, or local constitutional provision, statute,
ordinance, or regulation.
38. I am a former U.S. citizen who renounced my
citizenship in order to avoid taxation by the United
States.
37.
Other (specify):39.
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.
Your Inadmissibility Statement
In the space provided in Item Number 40., provide a statement
and a full explanation of the acts, convictions, and/or medical
conditions that you believe or you were told make you
inadmissible.
If you need extra space to complete your statement, use the
space provided in Part 10. Additional Information or attach a
separate letter. If you include a separate letter, indicate in Item
Number 39. that you are attaching a letter.
I falsely represented myself as a U.S. citizen.30.
I am subject to a civil penalty because I have been the
subject of a final order for violation of INA section
274C.
32.
31. I have been engaged in alien smuggling.
I have sought to procure an immigration benefit by
fraud or by concealing or misrepresenting a material
fact (immigration fraud or misrepresentation).
29.
Page 6 of 12Form I-601 12/02/19
2.c. City or Town
2.d. State 2.e. ZIP Code
2.f. Province
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Physical Address
Street Number
and Name
2.a.
2.h. Country
2.b.
Apt.
Flr.Ste.
Provide information for your U.S. citizen or lawful permanent
resident through whom you are eligible to submit this
application. In Item Number 9., provide a statement
explaining the extreme hardship that you or your qualifying
relative (U.S. citizen, lawful permanent resident, or other
qualified parent or child) has or will experience if you are
refused the immigration benefit you are seeking. It is not
necessary for an SIJ to complete Part 5. of the application.
2.g. Postal Code
Part 5. Information About Your Qualifying
Relatives
Select here if you are a VAWA self-petitioner and would
like to claim extreme hardship to yourself. (If you are only
claiming extreme hardship for yourself, you can skip to Item
Number 9. If you have additional qualifying relatives to
whom you would like to claim extreme hardship, provide
their information below.)
3. Daytime Telephone Number (if any)
Email Address (if any)4.
Contact Information
Relative's Full Name
Select this box if you have additional relatives through
whom you claim eligibility and use the space provided in
Part 10. Additional Information to provide the same
information as requested in Part 5., Item Numbers 1.a. - 8.
In the space provided below, explain the extreme hardship that
your qualifying relative (or yourself if you are a VAWA self-
petitioner) would experience if you are refused the immigration
benefit you are seeking. For more information on extreme
hardship, see Form I-601 Instructions. If you need extra space
to complete your statement, use the space provided in Part 10.
Additional Information or attach a separate letter. Indicate in
Item Number 9. if you are attaching a separate letter. The
letter must be submitted at the same time as your Form I-601
application.
6. What is your relative's immigration status?
Date of Birth (mm/dd/yyyy)8.
Relative's A-Number (if any)7.
►
A-
Statement From Applicant (Extreme Hardship)
9.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
Part 6. Information About Your Other Relatives
With Ties to the United States
Provide information for any other U.S. citizen, lawful permanent
resident, or any other family members you would like considered
in deciding your case. In the space provided in Item Number 9.,
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.
Relative's Full Name
5. What is your relative's relationship to you?
Other Information
Page 7 of 12Form I-601 12/02/19
Physical Address
Contact Information
Daytime Telephone Number (if any)3.
4. Email Address (if any)
Other Information
5. What is your relative's relationship to you?
6. What is your relative's immigration status?
Select this box if you have any other relatives with ties to
the United States and use the space provided in Part 10.
Additional Information to provide the same information
as requested in Part 6., Item Numbers 1.a. - 8.
Date of Birth (mm/dd/yyyy)8.
Relative's A-Number (if any)7.
►
A-
9.
In the space provided below, explain why you believe your
application should be approved as a matter of discretion, with
the favorable outweighing the unfavorable factors in your case.
For more information on discretion, see Form I-601 Instructions.
If you need extra space to complete your statement, use the
space provided in Part 10. Additional Information or attach a
separate letter. Indicate in Item Number 9. if you are attaching
a separate letter. The letter must be submitted at the same time
as your Form I-601 application.
Statement From Applicant (Discretion)
Part 6. Information About Your Other Relatives
With Ties to the United States (continued)
2.c. City or Town
Street Number
and Name
2.a.
2.b.
Apt.
Flr.Ste.
2.d. State 2.e. ZIP Code
2.f. Province
2.h. Country
2.g. Postal Code
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
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 8. read to me every
question and instruction on this application and my
answer to every question, in
1.a.
a language in which I am fluent, and I understood
everything.
,
Read the Penalties section of the Form I-601 Instructions
before completing this part. You must file Form I-601 while in
the United States.
Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
,
2.
At my request, the preparer named in Part 9.,
prepared this application for me based only upon
information I provided or authorized.
Page 8 of 12Form I-601 12/02/19
Part 8. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.
Provide the following information about the interpreter.
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
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.
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 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:
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.
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct
at the time of filing.
Date of Signature (mm/dd/yyyy)6.b.
Applicant's Signature (sign in ink)6.a.
Applicant's Signature
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.
3.h.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
Street Number
and Name
3.a.
Country
3.b. Apt.
Flr.Ste.
3.g. Postal Code
Interpreter's Contact Information
4.
Interpreter's Mobile Telephone Number (if any)5.
Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)6.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
which is the same language specified in Part 7., 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.
,
Page 9 of 12Form I-601 12/02/19
Part 8. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Signature
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature (sign in ink)7.a.
Provide the following information about the preparer.
Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Preparer's Business or Organization Name (if any)2.
Preparer's Mailing Address
3.h.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
Street Number
and Name
3.a.
Country
3.b. Apt.
Flr.Ste.
3.g. Postal Code
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Mobile Telephone Number (if any)
extends does not extend beyond the
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.a.
7.b.
Preparer's Statement
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, or 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.
8.a. Preparer's Signature (sign in ink)
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
I am an attorney or accredited representative and my
representation of the applicant in this case
preparation of this application.
Page 10 of 12Form I-601 12/02/19
Part 10. 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.
3.d.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
3.a. 3.b. 3.c.Page Number Part Number Item Number
►
A-
A-Number (if any)2.
4.d.
4.a. 4.b. 4.c.Page Number Part Number Item Number
5.d.
5.a. 5.b. 5.c.Page Number Part Number Item Number
6.d.
6.a. 6.b. 6.c.Page Number Part Number
Item Number
Page 11 of 12Form I-601 12/02/19
NOTE: The physician at the local health department in the area
where the alien plans to reside should complete this statement.
I also agree to report the alien if the alien has not reported
within 30 days after receiving notice from the Division of
Global Migration and Quarantine, CDC.
Satisfactory financial arrangements have been made. (This
statement does not relieve the alien from submitting evidence,
as required by a U.S. Consulate, to establish that the alien is not
likely to become a public charge.)
Upon admission to the United States, I will go directly to the
health department named in the section below; present all X-rays
used in the visa medical examination to substantiate diagnosis;
submit to such examinations, treatment, isolation, and medical
regimen as may be required; and remain under the prescribed
treatment or observation, whether on an inpatient or outpatient
basis, until discharged.
Within 30 days of the alien reporting for care, I agree to submit
a summary of my initial evaluation of the alien's condition,
indicate presumptive diagnosis, and provide test results and
plans for future care of the alien to the State Health Department
Official named in the Endorsement of State Health
Department Official section and to the Division of Global
Migration and Quarantine (E03), Centers for Disease
Control and Prevention (CDC), Atlanta, Georgia 30333.
I agree to supply any treatment or observation necessary for the
proper management and continued care of the alien's
tuberculosis condition.
Date of Signature (mm/dd/yyyy)1.b.
Signature of Applicant (sign in ink)
1.a.
4.c. City or Town
4.d. State 4.e. ZIP Code
Signature of Physician (sign in ink)5.a.
5.b. Date of Signature (mm/dd/yyyy)
6. Daytime Telephone Number
Email Address (if any)7.
Street Number
and Name
4.a.
4.b.
Apt. Flr.Ste.
8.c. City or Town
8.d. State 8.e. ZIP Code
Arrange for medical care (of the applicant) and have the
appropriate health departments complete Statement by Local
(City or County) Health Department and Endorsement of
State Health Department Official sections.
Address where you (the sponsor) or the applicant plan to reside
in the United States:
Provide the following information:
Street Number
and Name
8.a.
8.b.
Apt.
Flr.Ste.
Part 11. Statement for Applicants With a Class
A Tuberculosis Condition (As Defined By HHS
Regulations)
Arrangement for Medical Care by the Applicant or
His or Her Sponsor
Statement by Applicant
Statement by Local (City or County) Health
Department
To be completed for applicants with a Class A Tuberculosis
Condition (as defined by HHS Regulations).
I represent (select the appropriate box and give the complete
name, address, certification, and contact information of the
health department):
City Health Department
County Health Department
2.a.
2.b.
5.c. Physician's Family Name (Last Name)
Physician's Given Name (First Name)5.d.
Physician's Contact Information
Physical Address
Physician's Certification
Name of Health Department3.
Page 12 of 12Form I-601 12/02/19
NOTE: The State Health Department Official in the area
where the applicant plans to reside should complete this
statement.
Endorsement signifies recognition of the local health
department that completed the Statement by Local (City or
County) Health Department section for the purpose of
providing care and treatment of the applicant's tuberculosis
condition, and that the local health department is within your
jurisdiction. Endorsement also signifies recognition that the
applicant will be residing within your state's health jurisdiction.
Endorsed by:
Date of Signature (mm/dd/yyyy)9.b.
Signature of State Health Department Official (sign in ink)9.a.
Part 11. Statement for Applicants With a Class
A Tuberculosis Condition (As Defined By HHS
Regulations) (continued)
Endorsement of State Health Department Official
NOTE to the Applicant and his or her Sponsor: If you need
assistance, contact USCIS at the National Customer Service
Center at 1-800-375-5283. You may also schedule an
appointment online at www.uscis.gov. Select "Schedule an
Appointment" and follow the screen prompts to set up your
appointment. Once you finish scheduling an appointment, the
system will generate an appointment notice for you.
Name of State Health Department10.
11.c. City or Town
11.d. State 11.e. ZIP Code
12. Daytime Telephone Number
Email Address (if any)13.
Street Number
and Name
11.a.
11.b.
Apt.
Flr.Ste.
Contact Information
Physical Address
NOTE to the Applicant: If you are approved for a waiver and
after admission to the United States, you fail to comply with the
terms, conditions, and controls that were imposed with the grant
of the waiver, you may be subject to removal under INA
section 237(a).
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Form I-601: Application for Waiver of Grounds of (American Immigration Lawyers Association)

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Completed 29 July 2020

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