Fillable I-601a Form I-601A

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I-601a Form I-601A

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Page 1 of 9Form I-601A 02/13/19
Application for Provisional Unlawful Presence Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-601A
OMB No. 1615-0123
Expires 02/28/2021
Fee Stamp
For
USCIS
Use
Only
Relocated
Action Block
SentReceived
Initial Receipt
Resubmitted
START HERE - Type or print in black ink.
►
Select this box if
Form G-28 is
attached to represent
the applicant.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
To be completed by an
attorney or
BIA-accredited
representative (if any).
►
Part 1. Information About You
Alien Registration Number (A-Number) (if any)1.
U.S. Social Security Number (if any)
►
A-
Provide the following information about yourself.
2.
►
3. USCIS Online Account Number (if any)
Your Full Name
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
Other Names Used (if any)
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Middle Name
Your U.S. Mailing Address
Street Number
and Name
7.a.
In Care Of Name
7.b.
7.c. Apt. Ste. Flr.
7.d. City or Town
7.e. State 7.f. ZIP Code
10.
9.d. State 9.e. ZIP Code
9.c. City or Town
Street Number
and Name
9.a.
9.b. Flr.Ste.Apt.
If you answered "No" to Item Number 8., provide your
physical address in Item Numbers 9.a. - 9.e.
8. Is your current physical address the same as your mailing
address?
Gender
Male Female
Yes No
Other Information
Your U.S. Physical Address
11. Date of Birth (mm/dd/yyyy)
(USPS ZIP Code Lookup)
Page 2 of 9Form I-601A 02/13/19
Part 1. Information About You (continued)
12. City or Town of Birth
13. Country of Birth
14. Country of Citizenship or Nationality
Immigration Status (At the time of entry)19.
Place or Port-of-Entry (Actual or approximate city or town)
State
Date of Entry (On or about mm/dd/yyyy) 17.
Your Last Entry Into the United States
18.a.
18.b.
15.a.
Father's Family Name (Last Name)
16.b. Father's Given Name (First Name)
16.a.
Mother's Given Name (First Name) 15.b.
Mother's Family Name (Last Name)
Your Previous Entries Into the United States
To (On or about mm/dd/yyyy) 21.b.
You were previously in the United States as follows:
From (On or about mm/dd/yyyy)21.a.
Place or Port-of-Entry (Actual or approximate city or town)
State
20.a.
20.b.
Immigration Status (At the time of entry)22.
To (On or about mm/dd/yyyy) 24.b.
From (On or about mm/dd/yyyy)24.a.
Immigration Status (At the time of entry)25.
Are there other previous entries?26.
If you answered "Yes" to Item Number 26., include the
place of entry, dates, and your immigration status at the
time of entry for any other prior entries in the space
provided in Part 9. Additional Information.
Yes No
Your Immigration or Criminal History
State23.b.
23.a. Place or Port-of-Entry (Actual or approximate city or town)
Are you currently in removal, exclusion, or deportation
proceedings in which there is no final order issued by the
immigration judge, the Board of Immigration Appeals, a
DHS officer, or a Federal court yet? (This includes
proceedings under INA section 239, an exclusion or
deportation proceeding initiated before April 1,1997, a
Visa Waiver Program removal proceeding under INA
section 217, expedited removal under INA 235, and a
request for a judicial removal order under INA section
238(c))?
27.
Yes No
If you answered “No” to Item Number 27., go to Item
Number 29.a. If you answered “Yes” to Item Number
27., select the statement below (either Item Number
28.a. or 28.b.) that most accurately describes your current
situation.
NOTE: You may be eligible for a provisional
unlawful presence waiver. Provide a copy of the
administrative closure order. Also, if U.S.
Citizenship and Immigration Services (USCIS)
approves your provisional unlawful presence
waiver, you should seek termination or dismissal of
your removal, exclusion, or deportation proceedings
before you depart the United States for your
immigrant visa interview.
28.a. I am in removal, exclusion, or deportation
proceedings that are administratively closed and, at
the time of filing my Form I-601A, have not been
placed back on EOIR's calendar to continue my
removal, exclusion, or deportation proceedings.
Page 3 of 9Form I-601A 02/13/19
28.b.
I am currently in removal, exclusion, or deportation
proceedings that are not administratively closed, or
in removal, exclusion, or deportation proceedings
that were administratively closed, but EOIR has
placed my proceedings back on its calendar in order
to continue them.
Part 1. Information About You (continued)
NOTE: You are ineligible for a provisional
unlawful presence waiver unless your proceedings
are administratively closed at the time you file your
Form I-601A, and the proceedings have not been
put back on EOIR's calendar to continue your
removal, exclusion, or deportation after having been
previously administratively closed.
29.a.
29.b.
Are you currently subject to a final order of removal,
exclusion or deportation? (This includes an order entered
in proceedings under INA section 239, an exclusion or
deportation order entered in proceedings initiated before
April 1, 1997, a Visa Waiver Program removal order
under INA section 217, an expedited removal order
under
INA section 235, and a judicial order under INA section
238(c))?
Yes No
NOTE: If you answered "Yes" to Item Number 29.a.,
you are ineligible for a provisional unlawful presence
waiver unless you applied for, and USCIS has already
approved, an application for permission to reapply for
admission under INA section 212(a)(9)(A)(iii) and 8 CFR
212.2 on Form I-212, Application for Permission to
Reapply for Admission into the United States after
Deportation or Removal. If you have already applied for
and if USCIS has already granted you permission to
reapply for admission, provide the relevant information in
Item Number 29.b. If you answered "No" to Item
Number 29.a., go to Item Number 31.
USCIS Receipt Number for Your Approved Form I-212:
►
NOTE: You may also provide a copy of the approval
notice that USCIS sent to you when it approved your
Form I-212.
If you were granted voluntary departure in the past, but
then you withdrew your voluntary departure request or
otherwise terminated voluntary departure you should not
select "Yes" to Item Number 31. In this case you may be
in removal proceedings or you may be the subject of a
final order of removal, deportation, or exclusion. You
should select the statements that apply to you in Item
Numbers 27. - 28.b. or Item Number 29.a. If you filed
a motion to withdraw your voluntary departure request,
please submit a copy with your Form I-601A.
Answer Item Numbers 32. - 38. If you answer "Yes" to any
question in Item Numbers 32. - 38., your application for a
provisional unlawful presence waiver may be denied as a matter
of discretion. For each "Yes" response for Item Numbers 32. -
38., provide the location and date of the event and a brief
description in Part 9. Additional Information. For Item
Number 34., if you were arrested but not charged with any
crime or offense, provide a statement or other documentation
from the arresting authority, prosecutor's office, or court to
show that you were not charged with any crime or offense. If
you answer "Yes" to Item Number 35., you must provide all
related court dispositions.
Have you EVER knowingly and willfully given false or
misleading information to a U.S. Government official
while applying for an immigration benefit or to gain entry
or admission into the United States?
32.
Have you EVER been engaged in alien smuggling?33.
Yes No
Yes No
Have you EVER been arrested, cited, or detained by a
law enforcement officer (including immigration and
military officers) in the United States, your home country,
and/or any other country for any reason other than traffic
violations?
Yes No
34.
Have you EVER trafficked in or are you NOW trafficking
in any controlled substance?
Have you EVER been charged, indicted, convicted,
imprisoned, or jailed in the United States, your home
country, and/or any other country for any crime or
offense?
Yes
Yes
No
No
35.
36.
30.a. Has DHS served you with a DHS Form I-871, giving you
notice that DHS intends to reinstate a prior deportation,
exclusion, or removal order against you as permitted
under INA section 241(a)(5)?
Yes
NoYes
No
If you answered "Yes" to Item Number 30.a., has DHS
served you with a final decision reinstating a prior
deportation, exclusion, or removal order under INA
section 241(a)(5)?
31. Are you currently subject to a grant of voluntary
departure that has not expired and that was granted to you
by the immigration judge or the Board of Immigration
Appeals during removal, exclusion, or deportation
proceedings?
Yes No
NOTE: If you answered "Yes" to Item Number 31., you
are ineligible for a provisional unlawful presence waiver.
30.b.
Page 4 of 9Form I-601A 02/13/19
Part 1. Information About You (continued)
Are you NOW or have you EVER been engaged in
prostitution?
Yes
Yes
No
No
38.
37. Are you NOW or have you EVER knowingly assisted,
abetted, conspired, or colluded with others in the unlawful
trafficking of any controlled substance?
Answer Item Numbers 39.a. - 45. If you answer "Yes" to any
question in Item Numbers 39.a. - 45., your application for a
provisional unlawful presence waiver may be denied as a
matter of discretion. For each "Yes" response for Item
Numbers 39.a. - 45., provide a complete explanation in
Part 9. Additional Information.
Yes NoActs involving torture or genocide? 39.a.
Have you EVER ordered, incited, called for, committed, assisted,
helped with, or otherwise participated in any of the following:
39.b. Killing any person?
NoYes
Limiting or denying any person's ability to exercise
religious beliefs?
Yes
39.d.
Yes No
39.e.
Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
NoYes
No
Intentionally and severely injuring any person?39.c.
40.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, self-
defense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
NoYes
Have you EVER:
Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes No
40.b.
Have you EVER been a member of, assisted in, or
participated in any group, unit, or organization of any
kind in which you or other persons used any type of
weapon against any person or threatened to do so?
Yes No
41.
Have you EVER received any type of military,
paramilitary, or weapons training?
44.
Have you EVER used any person under 15 years of age
to take part in hostilities, or to help or provide services to
people in combat?
Yes No
45.
NoYes
Have you EVER recruited, enlisted, conscripted, or used
any person under 15 years of age to serve in or help an
armed force or group?
Yes No
43.
Part 2. Biographic Information
1.
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select only one box)
2.
Hair Color (Select only one box) 6.
Height
4. Weight
Feet Inches
3.
Pounds
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)
42. Have you EVER assisted or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
NoYes
Page 5 of 9Form I-601A 02/13/19
Part 3. Information About Your Immigrant
Visa Case
1.a.
1.b.
1.c.
1.d.
1.e.
2.a.
Provide the basis on which you are immigrating to the United
States using the check boxes below. (Select only one box)
Diversity Visa Program Selectee or Derivative
Immediate Relative Petition (Form I-130)
Employment-Based Petition (Form I-140), including
Derivatives
Special Immigrant/Widow Petition (Form I-360),
including Derivatives
Preference-Based Family Petition (Form I-130),
including Derivatives
If you selected Item Number 1.a. because you are a Diversity
Visa (DV) Program selectee or derivative, provide information
about your (or your spouse's or parent's) DV case:
DOS DV Case Number (KCC Case Number)
►
DV Program Selectee's Full Name (If you are a derivative and
your parent or spouse is the DV Program Selectee)
2.b. Family Name
(Last Name)
2.c. Given Name
(First Name)
2.d. Middle Name
3.a.
3.b.
If you selected Item Numbers 1.b., 1.c., 1.d., or 1.e. provide
the following information about the approved immigrant visa
petition (Form I-130, Form I-140, or Form I-360) that was filed
on your (or your spouse's or parent's) behalf, or that you used to
self-petition on your behalf, that is your basis to immigrate and
the related Department of State (DOS) immigrant visa
application.
►
USCIS Receipt Number
►
DOS Consular Case Number (NVC Case Number)
Petitioner Name (Provide the full name of the family member or
the company who petitioned for you (or your spouse or parent).)
3.c. Family Name
(Last Name)
3.d. Given Name
(First Name)
3.e. Middle Name
Company or Organization Name3.f.
Part 4. Information About Your Qualifying
Relative
Provide the following information about the qualifying relative
(the U.S. citizen or Lawful Permanent Resident (LPR) spouse or
parent) who would experience extreme hardship if you were
refused admission to the United States.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.a.
LPR Parent
LPR Spouse
2.d.
2.c.
2.b.
U.S. Citizen Spouse
U.S. Citizen Parent
Your Qualifying Relative's Full Name and
Relationship to You
Do you have more than one qualifying relative (U.S. citizen
or LPR spouse or parent)?
Yes No
If you answered "Yes" to Item Number 3., provide the
other qualifying relative's name and your relationship to
the qualifying relative in Item Numbers 4.a. - 5.d.
Also provide evidence of the U.S. citizenship or LPR
status of the other qualifying relative with your
application. See the What Evidence Must I Submit
With Form I-601A section of the Instructions.
3.
Your Other Qualifying Relative
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
Additional Qualifying Relative's Full Name and
Relationship to You
5.a.
5.b.
5.d.
5.c.
LPR Parent
LPR Spouse
U.S. Citizen Spouse
U.S. Citizen Parent
Page 6 of 9Form I-601A 02/13/19
Part 5. Statement From Applicant
In the space provided, explain in detail why you believe USCIS
should approve your application for a provisional unlawful
presence waiver as a matter of discretion. Provide all of the
reasons you believe support your application for this waiver,
including information about the extreme hardship your
qualifying relatives would experience if you were refused
admission to the United States. If you need extra space to
complete your statement, use the space provided in Part 9.
Additional Information.
Part 6. 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 7. 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.
,
NOTE: Read the Penalties section of the Form I-601A
Instructions before completing this section. You must file Form
I-601A while in the United States.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Applicant's Statement
,
2. At my request, the preparer named in Part 8.,
prepared this application for me based only upon
information I provided or authorized.
5. Applicant's Email Address (if any)
3. Applicant's Daytime Telephone Number
Applicant's Contact Information
Applicant's Mobile Telephone Number (if any)4.
Applicant's Declaration and 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 laws.
Page 7 of 9Form I-601A 02/13/19
Part 7. 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
Provide the following information about the interpreter.
Interpreter's Mailing Address
3.c. City or Town
Street Number
and Name
3.a.
3.b. Ste. Flr.Apt.
3.h.
3.d. State 3.e. ZIP Code
3.f. Province
Country
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.
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 Signature6.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.
Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and ,
which is the same language specified in Part 6., 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.
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature7.a.
Interpreter's Signature
I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:
Page 8 of 9Form I-601A 02/13/19
Preparer's Statement
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. 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.
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.
Preparer's Certification
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Signature
Part 8. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Business or Organization Name (if any)2.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Provide the following information about the preparer.
Preparer's Mailing Address
3.c. City or Town
Street Number
and Name
3.a.
3.b. Ste. Flr.Apt.
3.h.
3.d. State 3.e. ZIP Code
3.f. Province
Country
3.g. Postal Code
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)
Page 9 of 9Form I-601A 02/13/19
Part 9. Additional Information
3.d.
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.
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
7.d.
7.a. 7.b. 7.c.Page Number Part Number Item Number
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I-601a Form I-601A

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Completed 16 November 2019

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