Application for Provisional Unlawful Presence Waiver Department of Homeland Security U.S. Citizenship and Immigration Services For USCIS Use Only Initial Receipt Fee Stamp Resubmitted Relocated Received To be completed by an attorney or BIA-accredited representative if any. Relative continued Additional Qualifying Relative s Full Name and 5. a. 5. b. 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. List 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. Select this box if Form G-28 is attached to represent the applicant. Form I-601A OMB No* 1615-0123 Expires 07/31/2017 Action Block Sent Attorney State Bar Number if applicable Attorney or Accredited Representative USCIS ELIS Account Number if any START HERE - Type or print in black ink. Part 1. Information About You Your U*S* Mailing Address Provide the following information about yourself* 7. a* In Care Of Name Alien Registration Number A-Number if any A- U*S* Social Security Number if any Your Full Name 7. b. Street Number and Name 7. c* Other Names Used if any 5. a* Family Name Last Name 5. b. Given Name First Name Ste. Flr. 7. d. City or Town 7. e. State 4. c* Middle Name Apt. 7. f* ZIP Code Is your current physical address the same as your mailing address Yes No If you answered No to Item Number 8. provide your physical address in Item Numbers 9. a* - 9. e. Your U*S* Physical Address 9. a* Street Number 9. b. 9. c* City or Town 9. d. State 9. e. ZIP Code Other Information Date of Birth mm/dd/yyyy Gender Male Female Form I-601A 07/08/15 N Page 1 of 9 24. a* From mm/dd/yyyy City or Town of Birth 24. b. To mm/dd/yyyy Country of Birth Country of Citizenship or Nationality Immigration Status at the time of entry Are there other previous entries Your Immigration or Criminal History 16. a* Father s Family Name Last Name 16. b. Father s Given Name First Name Date of Entry mm/dd/yyyy 18. a* Place or Port-of-Entry City or Town 18. b. State statement below that most accurately describes your current situation* 28. a* Your Previous Entries Into the United States You were previously in the United States as follows 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. NOTE 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. 20. b. State Are you currently in removal exclusion or deportation proceedings This includes being subject to a final order Homeland Security DHS removal order that reinstates a prior removal exclusion or deportation order.
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