Fillable Ins-form-i-602 Application by Refugee for Waiver of Grounds of Excludability

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Ins-form-i-602 Application by Refugee for Waiver of Grounds of Excludability

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The Ins-form-i-602 Application by Refugee for Waiver of Grounds of Excludability form is 3 pages long and contains:

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  • 9 check-boxes
  • 25 other fields

Country of origin: US
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I have been declared inadmissible or ineligible for adjustment of status under the following section(s) of 212(a) of the Immigration
and Nationality Act (INA). (NOTE: Sections 212(a)(4), 212(a)(5), and 212(a)(7)(A) do not apply to refugees under Sections 207
or 209 of the INA.)
OMB No. 1615-0069; Exp. 12/31/2018
Middle NameFirst Name
City or TownPresent Address: ZIP Code
A-Number
Place of Birth
(City or Town)
Waiver of grounds of inadmissibility is granted.
For humanitarian reasons
Waiver of grounds of inadmissibility is denied. Basis for Denial:
To assure family unity In the public interest
PART 1.
PART 2.
Date of Action USCIS Office Director USCIS Field Office
To be completed by all applicants (Type or print in black ink)
Department of Homeland Security
U.S. Citizenship and Immigration Services
Applicant's Signature: Date:
I am inadmissible because: (List the specific acts, convictions, or physical or mental conditions. If you have active or suspected
tuberculosis, fully complete Part 3 on Page 2. If you have, or have had, a physical or mental disorder, and behavior associated with
the disorder that may pose, or has posed, a threat to the property, safety, or welfare of you or others, complete Part 3A on Page 2.)
Date of Birth
(mm/dd/yyyy)
Family Name (in capital letters)
Country of Birth
Number and Street State
I request a waiver of the grounds inadmissibility listed above for the following reasons: (Check the appropriate block and explain below)
I-602, Application by Refugee for
Waiver of Grounds of Excludability
Do not write below this line (For USCIS Use Only)
Country of Citizenship
Form I-602 (Rev. 12/19/16) Y Page 1
Form I-602 (Rev. 12/19/16) Y Page 2
PART 3.
A. Statement by Applicant
Signature: Date:
Upon admission to the United States I will:
1. Go directly to the physician or health facility named in Part B below; and
2. Present copies of diagnostic tests used in the medical examination to substantiate the diagnosis; and
3. Submit to counseling and such examinations, treatment, and medical regimen as may be required; and
4. Remain under prescribed treatment or observation whether on inpatient or outpatient basis, until I am discharged.
B. Statement by Physician and/or Health Facility
I agree to supply any treatment or observation necessary for the proper management of the applicant's tuberculosis condition.
I agree to submit Form CDC 75.18 to the health officer named below (Section C) either (a) within 30 days of the applicant's
reporting for care, indicating presumptive diagnosis, test results, and plans for future care of the applicant; or (b) 30 days after
receiving Form CDC 75.18, if the applicant has not reported. (NOTE: Military Hospitals should submit this form directly to the
Centers for Disease Control, Atlanta, GA 30333.)
Satisfactory financial arrangements have been made. (NOTE: This statement does not relieve the applicant of submitting such
evidence as the U.S. Consulate may require to establish that the applicant is not likely to become a public charge.)
Local Health Department Outpatient Clinic 1.
This section of Form I-602 may be executed by a private physician, health department, other public or private health facility, or
military hospital. NOTE: Upon arrival of the applicant in the United States, Form CDC 75.18, Report on Alien With Tuberculosis
Waiver, will be sent to the address given below.
To be completed for applicants with active or suspected tuberculosis or who have or have had a physical or mental
disorder and behavior associated with the disorder.
Signature of Physician: Date:
Address: (If military, enter name and address of receiving hospital)
4. Private Practice
Other Public or Private Health Facility3.
I represent: (Check the appropriate box and give the complete name and address of the facility.)
2. Military Hospital
NOTE to Applicant's Sponsor in United States: Arrange for medical care of the applicant and have the physician complete
Section B below.
NOTE to Applicant's Sponsor in United States: If medical care will be provided by a physician who checked Box 3 or 4 in
Section B above, have Section C completed by the local or State health officer who has jurisdiction in the area where the applicant
plans to reside in the United States. Provide the health officer with the address where the applicant plans to reside in the United
States.
Endorsement signifies recognition of the physician or facility for the purpose of providing care for tuberculosis. If the facility or
physician who signed in Section B is not in your health jurisdiction and is not familiar to you, you may wish to contact the health
officer responsible for the jurisdiction of the facility or physician prior to endorsing.
C. Endorsement by Local or State Health Officer
Enter name and address of the local health department to which Form CDC 75.18, Notice of Arrival of Alien With Tuberculosis
Waiver, will be sent when the applicant arrives in the United States.
Local Health Department Address:
Date:Signature:
Form I-602 (Rev. 12/19/16) Y Page 3
USCIS Privacy Act Statement
AUTHORITIES: The information requested on this application, and the associated evidence, is collected under Sections 207 and
209 of the Immigration and Nationality Act, as amended, as well as 8 CFR 207.3.
PURPOSE: The primary purpose for providing the requested information on this application is for a refugee who has been found
inadmissible to the United States for reasons such as a criminal conviction or certain health conditions to apply for a waiver of such
inadmissibility on grounds of humanitarian reasons, family unity or national interest. DHS will use the information you provide to
grant or deny the waiver.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any
requested evidence, may delay a final decision or result in denial of the waiver.
ROUTINE USES: DHS may share the information you provide on this application with other Federal, state, local, and foreign
government agencies and authorized organizations. DHS follows approved routine uses described in the associated published system
of records notices [DHS/USCIS-007 - Benefits Information System and DHS/USCIS-001 - Alien File, Index, and National File
Tracking System of Records] which you can find at www.dhs.gov/privacy
. DHS may also share the information, as appropriate, for
law enforcement purposes or in the interest of national security.
Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at
15 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden,
to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts
Ave NW., Washington, DC 20529-2140. OMB No. 1615-0069. Do not mail your application to this address.
Form I-602 (Rev. 12/19/16) Y Page 4
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Ins-form-i-602 Application by Refugee for Waiver of Grounds of Excludability

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Completed 2 July 2020

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