Fillable Ins-form-i-191 Application for Relief Under Former Section 212(c) of the Immigration and Nationality Act (INA)

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Ins-form-i-191 Application for Relief Under Former Section 212(c) of the Immigration and Nationality Act (INA)

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Form I-191 12/02/19 Page 1 of 17
To be completed by an
attorney or accredited
representative (if any).
Application for Relief Under Former Section 212(c)
of the Immigration and Nationality Act (INA)
Department of Homeland Security
U.S. Citizenship and Immigration Services
For
USCIS
Use
Only
USCIS
Form I-191
OMB No. 1615-0016
Expires 02/28/2021
Part 1. Information About You
START HERE - Type or print in black ink.►
Family Name (Last Name) Given Name (First Name) Middle Name
Your Full Name (do not provide a nickname)1.
Middle NameGiven Name (First Name)Family Name (Last Name)
Other Names Used2.
3. 4.Date of Birth (mm/dd/yyyy)
5.
Place of Birth
City/Town/Village of Birth
Country of Birth
State/Province of Birth
Alien Registration Number (A-Number) (if any)
►
A-
I am applying for permission to return to the United States under the authority contained in former section 212
(c)
of the Immigration
and Nationality Act (INA).
6.
Action BlockDate Fee Stamp
Attorney State Bar Number
(if applicable)
Select this box if
Form G-28 is
attached.
Attorney or Accredited Representative
USCIS Online Account Number (if any)
USCIS Online Account Number (if any)
►
RECEIVED
COMPLETEDRETD/TRANS OUT
TRANS IN
List all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this
section, use the space provided in Part 12. Additional Information.
7. Country of Citizenship or Nationality
Form I-191 12/02/19 Page 2 of 17
Admission With an Immigrant Visa at a Port-of-Entry
Adjustment of Status While in the United States
Port-of-Entry, If Known
USCIS Office
Means of Transportation
Part 1. Information About You (continued) (USPS ZIP Code Lookup)
10.
11.
Information About When and How You Became a Lawful Permanent Resident (LPR)
A.
B.
(mm/dd/yyyy)
Date When You Obtained Your LPR Status
You Obtained Your LPR Status Through (select only one)
In Care Of Name (if any)
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Mailing Address 8.
9. Physical Address
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
Postal Code CountryProvince
Passport Number Used at Last Entry Travel Document Number Used at Last Entry12.
13. Country of Issuance for Passport or Travel Document 14. Expiration Date of This Passport or Travel Document
(mm/dd/yyyy)
Form I-191 12/02/19 Page 3 of 17
Purpose of Trips
Place or Port-of-Entry
Date of Entry
(mm/dd/yyyy)
Means of Transportation
Returned To The United States
Part 1. Information About You (continued)
Information About Your Departures From and Returns To the United States
Since being admitted as an LPR, you have departed from and returned to the United States as follows:
15.
Departed From The United States
Means of Transportation
Date of Departure
(mm/dd/yyyy)
Place or Port-of-Departure
Form I-191 12/02/19 Page 4 of 17
Part 3. Information About Your Criminal Convictions
Criminal Conviction 1
The information you provide below relates to the criminal convictions for which you are seeking relief under former section 212(c) of
the Immigration and Nationality Act.
A.
1.
D.
Conviction Entered
If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy)
E.
Court Case Number
Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific
offense.)
Sentence, Probation, or Other Punishment ImposedH.
G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide
each separate citation.)
F.
C. Location of Court
Town or City State
B.Date (mm/dd/yyyy)
Based on Guilty or No Contest Plea
After Trial
Name of Court
Part 2. Biographic Information
Hair Color (Select only one box)
6.
Black
BlondBald (No
hair)
Brown
RedGray
Unknown/
Other
Sandy White
Not Hispanic or LatinoHispanic or Latino
Ethnicity (Select only one box)1.
American Indian or
Alaska Native
Race (Select all applicable boxes)
2.
Native Hawaiian or
Other Pacific Islander
Black or African
American
Asian
White
Feet InchesHeight3.
Weight 4. Pounds
5. Eye Color (Select only one box)
Blue GreenBrown Hazel MaroonGray Pink Unknown/OtherBlack
Form I-191 12/02/19 Page 5 of 17
Criminal Conviction 3
NOTE: If you were convicted more than three times, include the information for each additional conviction in Part 12. Additional
Information.
Part 3. Information About Your Criminal Convictions (continued)
A.
3.
D.
Conviction Entered
If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy)
E.
Court Case Number
Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific
offense.)
Sentence, Probation, or Other Punishment ImposedH.
G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide
each separate citation.)
F.
C. Location of Court
Town or City State
B.Date (mm/dd/yyyy)
Based on Guilty or No Contest Plea
After Trial
Name of Court
Criminal Conviction 2
A.
2.
D.
Conviction Entered
If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy)
E.
Court Case Number
Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific
offense.)
Sentence, Probation, or Other Punishment ImposedH.
G. Citation to Federal, State, or Local Law, as Stated in the Conviction Judgment (If there is more than one citation, provide
each separate citation.)
F.
C. Location of Court
Town or City State
B.Date (mm/dd/yyyy)
Based on Guilty or No Contest Plea
After Trial
Name of Court
Form I-191 12/02/19 Page 6 of 17
Part 4. Information About Your Residence
From (mm/dd/yyyy)
Physical Address 33.
To (mm/dd/yyyy)Date of Residence
From (mm/dd/yyyy)
Physical Address 44.
To (mm/dd/yyyy)
Date of Residence
Physical Address 22.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Date of Residence
1. Physical Address 1
From (mm/dd/yyyy) To (mm/dd/yyyy)
Date of Residence
Provide the following information about where you have lived during the last seven years.
List your most recent residence first and then every other residence where you have lived during the last seven years. There should be
no gaps in time. If you need extra space to complete this section, use the space provided in Part 12. Additional Information.
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/02/19 Page 7 of 17
List where you have worked full-time or part-time during the last seven years. If you need extra space to complete this section, use
the space provided in Part 12. Additional Information.
Provide the following information about your employment.
1.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Your Occupation
Employer 1
Name of Employer
Part 5. Information About Your Employment
Date
Physical Address 5
From (mm/dd/yyyy)
5.
To (mm/dd/yyyy)
Date of Residence
Part 4. Information About Your Residence (continued)
2.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Your Occupation
Employer 2
Date
Name of Employer
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/02/19 Page 8 of 17
Part 6. Information About Your Family
Provide the following information about your family (for example, spouse, children, and parents). If you need extra space to complete
this section, use the space provided in Part 12. Additional Information.
Spouse's Date of Birth (mm/dd/yyyy)
Family Name (Last Name) Given Name (First Name) Middle Name
Spouse's Current Legal Name
Information About Your SpouseA.
Spouse's Country of Birth
Spouse's Country of Citizenship or Nationality
Spouse's Physical Address
Employer 33.
From (mm/dd/yyyy) To (mm/dd/yyyy)
Your Occupation
Date
Part 5. Information About Your Employment (continued)
Name of Employer
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Apt. Flr. NumberSte.
CountryProvince
Street Number and Name
Form I-191 12/02/19 Page 9 of 17
Part 6. Information About Your Family (continued)
Child 2
Middle NameGiven Name (First Name)Family Name (Last Name)
Current Legal Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
B.
Middle NameGiven Name (First Name)Family Name (Last Name)
Child 1
Current Legal Name
Provide the following information about all of your children.
Information About Your Children
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/02/19 Page 10 of 17
Part 6. Information About Your Family (continued)
Child 4
Middle NameGiven Name (First Name)Family Name (Last Name)
Current Legal Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
Child 3
Middle NameGiven Name (First Name)Family Name (Last Name)
Current Legal Name
Date of Birth (mm/dd/yyyy)
Country of Birth
Country of Citizenship or Nationality
Current Address
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/02/19 Page 11 of 17
Part 6. Information About Your Family (continued)
Parent 2's Date of Birth (mm/dd/yyyy)
Family Name (Last Name) Given Name (First Name) Middle Name
Parent 2's Current Legal Name
Parent 2's Country of Birth
Parent 2's Country of Citizenship or Nationality
Parent 2's Physical Address
Sex FemaleMale
Parent 1's Date of Birth (mm/dd/yyyy)
Family Name (Last Name) Given Name (First Name) Middle Name
Parent 1's Current Legal Name
Information About Your Parents
Parent 1's Country of Birth
Parent 1's Country of Citizenship or Nationality
Parent 1's Physical Address
Parent 1
C.
Sex FemaleMale
Parent 2
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
Form I-191 12/02/19 Page 12 of 17
Part 8. Discretion
In the space provided below, explain why you believe your application should be approved as a matter of discretion, with the
favorable factors outweighing the unfavorable factors in your case. For more information on discretion, see the application
Instructions. If you need extra space to complete your statement, use the space provided in Part 12. Additional Information, or
attach a separate letter. Indicate in the space provided if you are including a separate letter. If you submit a separate letter, you must
submit the letter at the same time as your Form I-191 application.
Part 7. Other Grounds for Removal
If you believe you may be subject to removal on any grounds besides the criminal convictions listed in Part 3. Information About
Your Criminal Convictions, provide a full explanation of why you may be subject to removal.
The other grounds of removal may be any inadmissibility grounds in section 212(a) of the Immigration and Nationality Act or any
deportability grounds in section 237(a) of the Immigration and Nationality Act.
If you have a criminal history besides the criminal convictions listed in Part 3. Information About Your Criminal Convictions, list
these incidents and provide a full explanation. If you have ever been arrested or detained by any law enforcement officer for any
reason, and no charges were filed, include an original official statement by the arresting or detaining agency or applicable court order
confirming that no charges were filed.
If you were arrested or detained by any law enforcement officer for any reason and charges were filed, or if charges were filed against
you without an arrest, submit an original or court-certified copy of the complete arrest record and/or disposition for each incident (for
example, a dismissal order or an acquittal order).
If you need extra space to complete your statement, use the space provided in Part 12. Additional Information or attach a separate
letter.
Form I-191 12/02/19 Page 13 of 17
Part 9. Applicant's Statement, Contact Information, Certification, and Signature
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 of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further 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.
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 I provided or authorized all of the information in my application, I understand all of the
information contained in, and submitted with, my application, and that all of this information is complete, true, and correct.
NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, USCIS (or an immigration judge if you are in deportation, exclusion, or removal proceedings) may deny your application.
Applicant's Signature
Applicant's Signature Date of Signature (mm/dd/yyyy)6.
1) I reviewed and provided or authorized all of the information in my application;
3) All of this information was complete, true, and correct at the time of filing.
2) I understood all of the information contained in, and submitted with, my application; and
NOTE: Read the Penalties section of the Form I-191 Instructions before completing this part.
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.
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.
A.
Applicant's Statement Regarding the Interpreter
am fluent and I understood everything.
every question, in
The interpreter named in Part 10. read to me every question and instruction on this application and my answer toB.
Applicant's Statement
At my request, the preparer named in Part 11., ,
, a language in which I
prepared this application for me based only upon information I provided or authorized.
2. Applicant's Statement Regarding the Preparer
Applicant's Contact Information
3. 4.
5. Applicant's Email Address (if any)
Applicant's Daytime Telephone Number Applicant's Mobile Telephone Number (if any)
Form I-191 12/02/19 Page 14 of 17
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number Interpreter's Mobile Telephone Number (if any)
6. Interpreter's Email Address (if any)
5.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
, which is the same language specified in Part 9.,
Item B., in Item Number 1., 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 Certification, and has verified the accuracy of every answer.
Date of Signature (mm/dd/yyyy)Interpreter's Signature
Interpreter's Signature
7.
Part 10. Interpreter's Contact Information, Certification, and Signature
Interpreter's Given Name (First Name)Interpreter's Family Name (Last Name)
Provide the following information about the interpreter.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Interpreter's Mailing Address
Postal Code
City or Town State ZIP Code
Street Number and Name Apt. Flr. NumberSte.
CountryProvince
1.
3.
Form I-191 12/02/19 Page 15 of 17
Preparer's Contact Information
Preparer's Daytime Telephone Number Preparer's Mobile Telephone Number (if any)
Preparer's Email Address (if any)
4.
6.
5.
I am not an attorney or accredited representative but have prepared this application on behalf of
the applicant and with the applicant's consent.
I am an attorney or accredited representative and my representation of the applicant in this case
does not extend beyond the preparation of this application.
7.
Preparer's Statement
A.
B.
extends
NOTE: If you are an attorney or accredited representative, you must submit a completed Form
G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, 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 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 Signature Date of Signature (mm/dd/yyyy)
Preparer's Signature
8.
Preparer's Mailing Address
3. Street Number and Name Apt. Flr. NumberSte.
City or Town State ZIP Code
Postal CodeProvince Country
Part 11. Contact Information, Declaration, and Signature of the Person Preparing This Application, if
Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name
Preparer's Given Name (First Name)Preparer's Family Name (Last Name)1.
Preparer's Business or Organization Name (if any) 2.
Form I-191 12/02/19 Page 16 of 17
Part 12. 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.
A-Number (if any) ►
A-
3.
2.
Page Number B. Part Number C. Item Number
D.
A.
A.
A.
A.
Page Number
5.
Page Number
Part Number Item NumberC.B.
D.
6.
D.
B. C.
Item NumberPart NumberPage Number
Part Number Item Number
1. Family Name (Last Name) Given Name (First Name) Middle Name
C.B.
D.
4.
Form I-191 12/02/19 Page 17 of 17
Decision
For USCIS Use Only
Date of Action (mm/dd/yyyy)
Application granted upon the following terms and conditions:
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Ins-form-i-191 Application for Relief Under Former Section 212(c) of the Immigration and Nationality Act (INA)

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Completed 2 July 2020

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