Application For Advance Permission To Return To Unrelinquished Domicile
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Application For Advance Permission To Return To Unrelinquished Domicile Form. This is a Official Federal Forms form and can be use in US Citizenship And Immigration Services.
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Tags: Application For Advance Permission To Return To Unrelinquished Domicile, I-191, Official Federal Forms US Citizenship And Immigration Services,
OMB No. 1615-0016
I-191, Application for Advance Permission
to Return to Unrelinquished Domicile
Department of Homeland Security
U.S. Citizenship and Immigration Services
Fee Stamp
Action Block
Alien Registration Number
Date
(1) I hereby apply for permission to return to the United States under the authority contained in Section 212(c) of the Immigration and Nationality Act.
MY NAME IS:
(First)
(Middle)
(Last)
DATE OF BIRTH: (mm/dd/yyyy) PLACE OF BIRTH: (City, Province, Country)
I AM A CITIZEN/NATIONAL OF: (Country)
PRESENT ADDRESS: (Street and number, apt. no., city, state, country)
(2) I was lawfully admitted to the United States for permanent residence at:
PORT OF ENTRY/DHS OFFICE:
DATE: (mm/dd/yyyy)
NAME OF VESSEL OR OTHER MEANS OF CONVEYANCE:
(3) Since that admission I have departed from and reentered the United States as follows:
DEPARTED FROM THE UNITED STATES
Port
Date
(mm/dd/yyyy)
RETURNED TO THE UNITED STATES
Vessel or Other Means
of Conveyance
Date
(mm/dd/yyyy)
Port
PURPOSE OF TRIP
Vessel or Other Means
of Conveyance
(4) During the past 7 years I have resided at the following places: (List present address first)
(Complete Address - Include Apt. No.)
From -
ToPresent time
(5) During the past 7 years I have been employed as follows: (List present employment first)
From -
To -
Occupation or Type of
Business
Address
Employer's Name
(6) My immediate family (spouse, unmarried minor children and parents) consists of the following persons:
Name
(7) I
Relation
Date and Country of Birth
Citizen of
depart(ed) temporarily from the United States on or about
(Intend to or have)
in
and will remain
(Date - mm/dd/yyyy)
approximately
, for the purpose of
(Country)
(Length of Time)
; and expect to apply for admission at
Remarks:
Present Address
RECEIVED
TRANS. IN
(Port)
RET'D-TRANS. OUT COMPLETED
Form I-191 (Rev. 04/08/11) Y
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(8) I believe I may be inadmissible to the United States for the following reasons:
I understand that the information herein contained may be used in any criminal or civil proceedings, including removal, hereafter instituted against me.
I certify that the statements above are true and correct to the best of my knowledge and belief.
(Signature of Applicant)
Signature of person preparing form, if other than applicant.
I declare that the document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.
(Signature)
Decision:
Application granted upon the following terms and conditions:
(Address)
(Date)
DATE
OF
ACTION
DD
DISTRICT
Form I-191 (Rev. 04/08/11) Y Page 2
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