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I-191 (ILW.COM)

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The I-191 (ILW.COM) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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COMPLETED
(Length of Time)
(Date - mm/dd/yyyy)
Fee Stamp
Action Block
Alien Registration Number
Date
(1) I hereby apply for permission to return to the United States under the authority contained in Section 212(c) of the Immigration and Nationality Act.
(Middle)
(Last)
(First)
I AM A CITIZEN/NATIONAL OF: (Country)
PLACE OF BIRTH: (City, Province, Country)
DATE OF BIRTH: (mm/dd/yyyy)
PRESENT ADDRESS: (Street and number, apt. no., city, state, country)
(2) I was lawfully admitted to the United States for permanent residence at:
NAME OF VESSEL OR OTHER MEANS OF CONVEYANCE:
PORT OF ENTRY/DHS OFFICE:
DATE: (mm/dd/yyyy)
(3) Since that admission I have departed from and reentered the United States as follows:
RETURNED TO THE UNITED STATES
PURPOSE OF TRIP
DEPARTED FROM THE UNITED STATES
Port
Date
Vessel or Other Means
of Conveyance
Port
(4) During the past seven years I have resided at the following places: (List present address first)
(Complete Address - Include Apt. No.)
From -
To-
Present time
(5) During the past seven years I have been employed as follows: (List present employment first)
From -
To -
Address
Occupation or Type of
Business
(6) My immediate family (spouse, unmarried minor children and parents) consists of the following persons:
Name
Relation
Date and Country of Birth
Citizen of
Present Address
(7) I
depart(ed) temporarily from the United States on or about
approximately
, for the purpose of
(Country)
; and expect to apply for admission at
RECEIVED
TRANS. IN
RET'D-TRANS. OUT
Department of Homeland Security
U.S. Citizenship and Immigration Services
I-191, Application for Advance Permission
to Return to Unrelinquished Domicile
(mm/dd/yyyy)
Date
(mm/dd/yyyy)
Vessel or Other Means
of Conveyance
Employer's Name
and will remain
Form I-191 (Rev. 07/30/07)Y
OMB No. 1615-0016; Expires 06/30/2010
(Intend to or have)
in
(Port)
Remarks:
(Signature of Applicant)
(8) I believe I may be inadmissible to the United States for the following reasons:
I understand that the information herein contained may be used in any criminal or civil proceedings, including removal, hereafter instituted against me.
I certify that the statements above are true and correct to the best of my knowledge and belief.
Signature of person preparing form, if other than applicant.
I declare that the document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.
(Signature)
(Address)
(Date)
Decision:
Application granted upon the following terms and conditions:
DATE
OF
ACTION
DD
DISTRICT
Form I-191 (Rev. 07/30/07)Y Page 2
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I-191 (ILW.COM)

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Completed 9 January 2021

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