I-601A Application for Provisional Unlawful Presence Waiver

Complete the I-601A Application for Provisional Unlawful Presence Waiver Form accurately. The purpose of this Form is:” Certain immediate relatives of U.S. Citizens may use this form to request a provisional unlawful presence waiver under Immigration and Nationality Act Section 212 (a)(9)(B) and 8 CFR 212.7(e), before departing the United States to appear at a U.S. Embassy or consulate for an immigrant visa interview. For more information see the Provisional Unlawful Presence Waiver web page.”-http://www.uscis.gov/i-601a

Download

Recommended

Preview

Application for Provisional Unlawful Presence Waiver
  Department of Homeland SecurityU.S. Citizenship and Immigration Services
Initial Receipt
Fee Stamp
  USCISForm I-601A
OMB No. 1615-0123Expires 03/31/2015
Action Block
 ForUSCISUse

Only

Resubmitted
Received
Relocated
Sent
 To Be Completed by an Attorney orBIA-Accredited Representative, if any.
Check box if G-28 is attached to represent the applicant.
Attorney State License Number:
► START HERE – Type or print in black ink.
Part 1. Information About Applicant
Provide the following information about yourself.
1.
Alien Registration Number (A-Number) (if applicable)
► A-
2.
U.S. Social Security Number (optional)
5.a. Family Name(Last Name)
5.b. Given Name(First Name)
5.c. Middle Name
Home Address (where you physically reside)
6.a. Street Numberand Name
6.b. Apt.
Ste.
Flr.
Your Full Name
3.a. Family Name(Last Name)
3.b. Given Name(First Name)
3.c. Middle Name
6.c. City or Town
6.d. State
6.e. Zip Code
Mailing Address (if different from Home Address)
7.a. In Care Of Name
Other Names Used (if any)
4.a. Family Name(Last Name)
4.b. Given Name(First Name)
4.c. Middle Name
7.b. Street Numberand Name
7.c. Apt.
Ste.
Flr.
7.d. City or Town
7.e. State
7.f.
Zip Code
Form I-601A 03/04/13
Page 1 of 6

 

Part 1. Information About Applicant (continued)
Contact Information
8.
Daytime Phone Number (if any)
Extension
21.a. Place or Port of Entry (City or Town)
21.b. State
22.a. Date From (mm/dd/yyyy) ►
22.b. Date To
23.
(mm/dd/yyyy) ►
(
9.
)
E-mail Address (if any)
Immigration Status (at the time of entry)
Birth and Citizenship
10.
11.
Date of Birth
(mm/dd/yyyy) ►
24.
Are there other previous entries?
Yes
No
City or Town of Birth
If “Yes,” include the place of entry, dates, and immigrationstatus for previous entries in Part 5, AdditionalInformation, of this form.
12.
Province of Birth (if applicable)
Immigration or Criminal History
13.
Country of Birth
25.
Are you currently in removal proceedings (this includesbeing subject to a final removal order or to a DHS orderreinstating a prior removal order)?

YesNo

Note: If you answered “No,” skip to Item Number 27.
Note: If your case has been administratively closed, youare still “in removal proceedings” until the Department ofJustice, Executive Office for Immigration Review (EOIR)

terminates or dismisses your case. However, you are

eligible to apply for a provisional unlawful presence waiver

if EOIR has not placed your removal proceedings back on

EOIR’s calendar to continue your removal proceedings.

26.
16.b. State
17.
Immigration Status (at the time of entry)
If you answered “Yes” to Item Number 25., select thestatement below that most accurately describes yourcurrent situation:
I am in removal proceedings that are administrativelyclosed and have not been placed back on EOIR’scalendar to continue my removal proceedings, at the

time of filing a Form I-601A.

Note: Provide a copy of the administrative closurenotice. You should seek termination or dismissal ofyour removal proceedings before you depart the

United States if your application for a provisional

unlawful presence waiver is approved.

I am now subject to a final order of removal,deportation, or exclusion, or to the reinstatement of aprior removal order.
I am subject to a DHS order reinstating a priorremoval order.
I am currently in removal proceedings that are notadministratively closed, or I am currently in removalproceedings that were administratively closed, but my

proceedings have been placed back on EOIR’s

calendar to continue my removal proceedings.

Page 2 of 6
14.
Country of Citizenship
Last Entry Into the United States
15.
Date of Entry (mm/dd/yyyy)►
16.a. Place or Port of Entry (City or Town)
Previous Entries Into the United States
Applicant was previously in the United States as follows:
18.a. Place or Port of Entry (City or Town)
18.b. State
19.a. Date From (mm/dd/yyyy) ►
19.b. Date To
20.
(mm/dd/yyyy) ►
Immigration Status (at the time of entry)
Form I-601A 03/04/13

 

27.
Have you ever knowingly and willfully given false ormisleading information to a U.S. Government officialwhile applying for an immigration benefit or to gain entry

or admission into the United States?

YesNo

Have you ever knowingly assisted or attempted to assistthe entry of someone, even a family member, into theUnited States without the benefit of a valid travel

document in violation of U.S. law?

NoYes

Have you ever been arrested, cited, or detained by a lawenforcement officer (including immigration and militaryofficers) in the United States, your home country, and/or

any other country for any reason other than traffic

violations?

NoYes

Have you ever been charged, indicted, convicted,imprisoned or jailed in the United States, your homecountry, and/or any other country for any crime or

offense?

NoYes

Petitioner’s Full Name
2.a. Family Name(Last Name)
2.b. Given Name(First Name)
2.c. Middle Name
3.
Petitioner’s Relationship to Applicant (Select only one)
U.S. Citizen Spouse
U.S. Citizen Parent
U.S. Citizen Son or Daughter
Self (I-360 petitioner only)
Immigrant Visa Processing
4.
Consular Case Number (NVC Case Number)
28.
29.
30.
Have you ever engaged in, ordered, incited, assisted orotherwise participated in any of the following:
31.a. Acts involving torture, genocide, orhuman trafficking?
31.b. Killing any person?
31.c. Severely injuring any person?
Yes
Yes
Yes
No
No
No
5.
Did the Department of State initially act beforeJanuary 3, 2013, to schedule you to appear at a U.S.Embassy or consulate for an immigrant visa interview

based on the approved immediate relative petition listed

in Part 2., Item Number 1.?

YesNo

Note: USCIS may reject or deny your application if youanswer “Yes,” do not answer the question, or answer”No” but DOS records indicate that DOS initially acted

prior to January 3, 2013, to schedule you for an

immigrant visa interview.

31.d. Any kind of sexual contact or relations with any personwho was being forced or threatened?YesNo
Note: If you answered “Yes” to any item in Item Numbers27.-31.d., you may be ineligible for a provisional unlawfulpresence waiver, and your application may be denied. For each

“Yes” response, provide the location and date of the event, and

a brief description in Part 5., Additional Information, of this

form. For Item Number 29., if you were not charged with any

crime or offense, provide a statement or other documentation

from the arresting authority or prosecutor’s office to show that

you were not charged with any crime or offense. If you

answered “Yes” to Item Number 30., you must provide all

related court dispositions.

Part 3. Information About Qualifying Relative
Provide the following information about the U.S. citizen spouseor parent (qualifying relative) who would experience extremehardship if you were refused admission to the United States:
Qualifying Relative’s Full Name
1.a. Family Name(Last Name)
1.b. Given Name(First Name)
1.c. Middle Name
2.
Relationship to Applicant
U.S. Citizen Spouse
U.S. Citizen Parent
Part 2. Information About Immediate RelativePetition and Immigrant Visa Processing
Provide the following information about the approved immediaterelative petition (Form I-130 or I-360) and the related immigrantvisa application.
Approved Visa Petition
1.
USCIS Receipt Number
Form I-601A 03/04/13
Page 3 of 6

 

Part 3. Information About Qualifying Relative(continued)
3.
Do you have more than one qualifying relative (U.S. citizenspouse or parent)?YesNo
If you answered “Yes” provide the name, relationship andevidence of the U.S. citizenship of the other qualifyingrelative in Part 5., Additional Information, of this form.
Part 4. Statement From Applicant
In the space provided, explain in detail why you believe yourapplication for a provisional unlawful presence waiver shouldbe approved as a matter of discretion. List all of the reasons

you believe support your application for a provisional unlawful

presence waiver, including information about the extreme

hardship your qualifying relatives would experience if you were

refused admission to the United States.

Form I-601A 03/04/13
Page 4 of 6

 

Part 5. Additional Information
If you need more space to provide any additional informationwithin this application, please use the space below. If yourequire more space than what is provided in this section, you

may use a separate sheet(s) of paper. You must include your

full name on each sheet of paper along with the Page Number,

Part Number, and Item Number related to your explanation.

Part 6. Signature of Applicant (Read the Penaltiessection of the instructions before you sign thisapplication.)
I certify, under penalty of perjury under the laws of the UnitedStates, that this application and the evidence submitted with it areall true and correct to the best of my knowledge and abilities. I

authorize the release of any information from my records that U.S.

Citizenship and Immigration Services (USCIS) needs to determine

my eligibility for this provisional unlawful presence waiver.

I further authorize release of information contained in this form,supporting documents, and my USCIS records to other entitiesand persons where necessary for the administration of the U.S.

immigration laws.

1.a. Signature of Applicant
1.b. Date of Signature (mm/dd/yyyy) ►
Part 7. Signature and Contact Information ofPerson Preparing This Application (if other thanthe applicant)
NOTE: If you are an attorney or BIA-accredited representative,you must submit a completed Form G-28, Notice of Entry ofAppearance as Attorney or Accredited Representative, along

with this form.

1.
Attorney or Representative: In the event of a Request forEvidence (RFE), may USCIS contact you by e-mail?
Yes
No
Preparer’s Full Name
Provide the following information concerning the preparer:
2.a. Preparer’s Family Name (Last Name)
2.b. Preparer’s Given Name (First Name)
3.
Preparer’s Business or Organization Name
Form I-601A 03/04/13
Page 5 of 6

 

Part 7. Signature and Contact Information ofPerson Preparing This Application (continued)
Preparer’s Mailing Address
4.a. Street Numberand Name
4.b. Apt.
Ste.
Flr.
Part 8. Signature of Interpreter
1.
Language Used
4.c. City or Town
4.d. State
4.f.
Postal Code
4.e. Zip Code
I certify that I am fluent in English and the language above. Ifurther certify that I have read each and every question andinstruction on this form, as well as the answer to each question,

to this applicant in the above-mentioned language, and that the

applicant has informed me that he or she has understood each

and every instruction and question of the form, as well as the

answer to each question on the form.

2.a. Signature of Interpreter
4.g. Province
4.h. Country
2.b. Date of Signature (mm/dd/yyyy) ►
Interpreter’s Information
3.a. Interpreter’s Family Name (Last Name)
Extension
Preparer’s Contact Information
5.
Preparer’s Daytime Phone Number
3.b. Interpreter’s Given Name (First Name)
(
6.
)
Preparer’s E-mail Address (if any)
Declaration of Preparer
I declare that this document was prepared by me at the request ofthe applicant, and it is based on all information of which I haveknowledge and/or was provided to me by the above named person

in response to the exact questions contained on this form. I have

not knowingly withheld any information or provided responses

for the applicant.

7.a. Signatureof Preparer
7.b. Date of Signature (mm/dd/yyyy) ►
Form I-601A 03/04/13
Page 6 of 6