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 Date For USCIS Use Only Fee Stamp Action Block USCIS Form I-191 OMB No. 1615-0016 Expires 09/30/2018 RECEIVED TRANS IN RETD/TRANS OUT COMPLETED To be completed by an attorney or accredited representative (if any). Select this box if Form G-28 is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink. Part 1. Information About You 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). 1. Your Full Name (do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name 2. Other Names Used 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. Family Name (Last Name) Given Name (First Name) Middle Name 3. Date of Birth (mm/dd/yyyy) 4. Alien Registration Number (A-Number) (if any) A5. USCIS Online Account Number (if any) 6. Place of Birth City/Town/Village of Birth State/Province of Birth Country of Birth 7. Country of Citizenship or Nationality Form I-191 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 17 Part 1. Information About You (continued) 8. Mailing Address In Care Of Name (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 9. Physical Address Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 10. Information About When and How You Became a Lawful Permanent Resident (LPR) A. Date When You Obtained Your LPR Status (mm/dd/yyyy) B. You Obtained Your LPR Status Through (select only one) Admission With an Immigrant Visa at a Port-of-Entry Port-of-Entry, If Known Means of Transportation Adjustment of Status While in the United States USCIS Office 11. Passport Number Used at Last Entry 12. Travel Document Number Used at Last Entry 13. Country of Issuance for Passport or Travel Document 14. Expiration Date of This Passport or Travel Document (mm/dd/yyyy) Form I-191 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 17 Part 1. Information About You (continued) 15. 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: Departed From The United States Place or Port-of-Departure Date of Departure (mm/dd/yyyy) Means of Transportation Returned To The United States Place or Port-of-Entry Date of Entry (mm/dd/yyyy) Means of Transportation Purpose of Trips Form I-191 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 17 Part 2. Biographic Information 1. Ethnicity (Select only one box) Hispanic or Latino 2. Not Hispanic or Latino Race (Select all applicable boxes) White Asian Black or African American Inches American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 3. 4. 5. Height Weight Feet Pounds Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/ Other Part 3. Information About Your Criminal Convictions 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. 1. Criminal Conviction 1 A. Date (mm/dd/yyyy) B. Name of Court C. Location of Court Town or City State D. Court Case Number E. Conviction Entered After Trial Based on Guilty or No Contest Plea If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy) F. Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific offense.) 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.) H. Sentence, Probation, or Other Punishment Imposed Form I-191 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 17 Part 3. Information About Your Criminal Convictions (continued) 2. Criminal Conviction 2 A. Date (mm/dd/yyyy) B. Name of Court C. Location of Court Town or City State D. Court Case Number E. Conviction Entered After Trial Based on Guilty or No Contest Plea If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy) F. Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific offense.) 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.) H. Sentence, Probation, or Other Punishment Imposed 3. Criminal Conviction 3 A. Date (mm/dd/yyyy) B. Name of Court C. Location of Court Town or City State D. Court Case Number E. Conviction Entered After Trial Based on Guilty or No Contest Plea If based on guilty or no contest plea, give the date of the guilty or no contest plea (mm/dd/yyyy) F. Specific Offense as Stated in the Conviction Judgment (If there is more than one offense, provide the name of each specific offense.) 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.) H. Sentence, Probation, or Other Punishment Imposed NOTE: If you were convicted more than three times, include the information for each additional conviction in Part 12. Additional Information. Form I-191 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 17 Part 4. Information About Your 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. 1. Physical Address 1 Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Date of Residen