Page 1 of 9Form I-601A 02/13/19 Application for Provisional Unlawful Presence Waiver Department of Homeland Security U.S. Citizenship and Immigration ServicesUSCIS Form I-601A OMB No. 1615-0123 Expires 02/28/2021 Fee Stamp For USCIS Use Only Relocated Action Block Sent Received Initial Receipt ResubmittedSTART HERE - Type or print in black ink. Select this box if Form G-28 is attached to represent the applicant.Attorney State Bar Number (if applicable)Attorney or Accredited Representative USCIS Online Account Number (if any) To be completed by an attorney or BIA-accredited representative (if any). Part 1. Information About YouAlien Registration Number (A-Number) (if any)1.U.S. Social Security Number (if any)A- Provide the following information about yourself.2. 3.USCIS Online Account Number (if any) Your Full Name4.a.Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Names Used (if any)5.a.Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 6.a.Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name Your U.S. Mailing AddressStreet Number and Name7.a. In Care Of Name 7.b. 7.c. Apt. Ste. Flr.7.d. City or Town 7.e. State7.f.ZIP Code 10.9.d.State9.e.ZIP Code9.c.City or Town Street Number and Name9.a. 9.b. Flr. Ste. Apt.If you answered "No" to Item Number 8., provide your physical address in Item Numbers 9.a. - 9.e.8.Is your current physical address the same as your mailing address?Gender Male Female Yes No Other Information Your U.S. Physical Address 11.Date of Birth (mm/dd/yyyy) (USPS ZIP Code Lookup) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 9Form I-601A 02/13/19 Part 1. Information About You (continued)12.City or Town of Birth 13.Country of Birth 14.Country of Citizenship or NationalityImmigration Status (At the time of entry)19. Place or Port-of-Entry (Actual or approximate city or town) StateDate of Entry (On or about mm/dd/yyyy) 17. Your Last Entry Into the United States18.a.18.b. 15.a. Father's Family Name (Last Name) 16.b.Father's Given Name (First Name) 16.a.Mother's Given Name (First Name) 15.b.Mother's Family Name (Last Name) Your Previous Entries Into the United StatesTo (On or about mm/dd/yyyy) 21.b.You were previously in the United States as follows:From (On or about mm/dd/yyyy)21.a. Place or Port-of-Entry (Actual or approximate city or town) State 20.a.20.b.Immigration Status (At the time of entry)22. To (On or about mm/dd/yyyy) 24.b.From (On or about mm/dd/yyyy)24.a. Immigration Status (At the time of entry)25. Are there other previous entries?26.If you answered "Yes" to Item Number 26., include the place of entry, dates, and your immigration status at the time of entry for any other prior entries in the space provided in Part 9. Additional Information. Yes No Your Immigration or Criminal HistoryState 23.b.23.a.Place or Port-of-Entry (Actual or approximate city or town) Are you currently in removal, exclusion, or deportation proceedings in which there is no final order issued by the immigration judge, the Board of Immigration Appeals, a DHS officer, or a Federal court yet? (This includes proceedings under INA section 239, an exclusion or deportation proceeding initiated before April 1,1997, a Visa Waiver Program removal proceeding under INA section 217, expedited removal under INA 235, and a request for a judicial removal order under INA section 238(c))?27. Yes NoIf you answered 223No224 to Item Number 27., go to Item Number 29.a. If you answered 223Yes224 to Item Number 27., select the statement below (either Item Number 28.a. or 28.b.) that most accurately describes your current situation.NOTE: You may be eligible for a provisional unlawful presence waiver. 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.28.a. 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. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 9Form I-601A 02/13/19 28.b. I am currently in removal, exclusion, or deportation proceedings that are not administratively closed, or in removal, exclusion, or deportation proceedings that were administratively closed, but EOIR has placed my proceedings back on its calendar in order to continue them. Part 1. Information About You (continued)NOTE: You are ineligible for a provisional unlawful presence waiver unless your proceedings are administratively closed at the time you file your Form I-601A, and the proceedings have not been put back on EOIR's calendar to continue your removal, exclusion, or deportation after having been previously administratively closed.29.a.29.b.Are you currently subject to a final order of removal, exclusion or deportation? (This includes an order entered in proceedings under INA section 239, an exclusion or deportation order entered in proceedings initiated before April 1, 1997, a Visa Waiver Program removal order under INA section 217, an expedited removal order under INA section 235, and a judicial order under INA section 238(c))? Yes NoNOTE: If you answered "Yes" to Item Number 29.a., you are ineligible for a provisional unlawful presence waiver unless you applied for, and USCIS has already approved, an application for permission to reapply for admission under INA section 212(a)(9)(A)(iii) and 8 CFR 212.2 on Form I-212, Application for Permission to Reapply for Admission into the United States after Deportation or Removal. If you have already applied for and if USCIS has already granted you permission to reapply for admission, provide the relevant information in Item Number 29.b. If you answered "No" to Item Number 29.a., go to Item Number 31.USCIS Receipt Number for Your Approved Form I-212: NOTE: You may also provide a copy of the approval notice that USCIS sent to you when it approved your Form I-212.If you were granted voluntary departure in the past, but then you withdrew your voluntary departure request or otherwise terminated voluntary departure you should not select "Yes" to Item Number 31. In this case you may be in removal proceedings or you may be the subject of a final order of removal, deportation, or exclusion. You should select the statements that apply to you in Item Numbers 27. - 28.b. or Item Number 29.a. If you filed a motion to withdraw your voluntary departure request, please submit a copy with your Form I-601A. Answer Item Numbers 32. - 38. If you answer "Yes" to any question in Item Numbers 32. - 38., your application for a provisional unlawful presence waiver may be denied as a matter of discretion. For each "Yes" response for Item Numbers 32. - 38., provide the location and date of the event and a brief description in Part 9. Additional Information. For Item Number 34., if you were arrested but not charged with any crime or offense, provide a statement or other documentation from the arresting authority, prosecutor's office, or court to show that you were not charged with any crime or offense. If you answer "Yes" to Item Number 35., you must provide all related court dispositions.Have you EVER knowingly and willfully given false or misleading information to a U.S. Government official while applying for an immigration benefit or to gain entry or admission into the United States?32.Have you EVER been engaged in alien smuggling?33. Yes No Yes NoHave you EVER been arrested, cited, or detained by a law enforcement officer (including immigration and military officers) in the United States, your home country, and/or any other country for any reason other than traffic violations? Yes No34.Have you EVER trafficked in or are you NOW trafficking in any controlled substance?Have you EVER been charged, indicted, convicted, imprisoned, or jailed in the United States, your home country, and/or any other country for any crime or offense? Yes Ye