Application for Waiver of Grounds of Inadmissibility Department of Homeland Security U.S. Citizenship and Immigration Services For Government Use Only Alien Registration Number (A-Number of This Applicant): AFee Receipt Number (This application): Action Block USCIS Form I-690 OMB No. 1615-0032 Expires 12/31/2018 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) APPLICANT: Start here. Type or print in black ink. Read the instructions before completing this application. If you need extra space to complete any item within this application, use Part 6. Additional Information or attach a separate sheet of paper; type or print your name and Alien Registration Number (A-Number) (if any), at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. Part 1. Information About You (the Applicant) Your Current Legal Name 1. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Mailing Address 2. In Care Of Name (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 3. Is your current mailing address the same as your physical address? If you answered "No" to Item Number 3., provide your physical address in Item Number 4. Yes No Form I-690 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 8 Part 1. Information About You (the Applicant) (continued) Physical Address 4. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Other Information 5. City/Town/Village of Birth 6. Country of Birth 7. Date of Birth (mm/dd/yyyy) 8. Alien Registration Number (if any) A9. USCIS Online Account Number (if any) 10. U.S. Social Security Number (if any) Part 2. Additional Information About You 1. 2. 3. 4. Date Primary Application Filed (mm/dd/yyyy) Type of Primary Application Relating Receipt Number I am applying for a waiver of (Select all that apply): INA section (Please see the instructions for more information on these sections) 212 (a) (1)(A)(i), (ii), (iii) or (iv) 212(a)(6)(D) and/or (E) 212(a)(9)(B)(i)(I) or (i)(II) 212 (a)(2)(A)(i)(II) 212(a)(8)(A) and/or (B) 212(a)(9)(C)(i)(I) or (i)(II) 212 (a)(6)(A)(i) 212(a)(9)(A)(i) or (ii) 212(a)(6)(C)(i) or (ii) Permanent Residence (Form I-698) Temporary Residence (Form I-687 or Form I-700) 212 (a)(10)(A), (B), (C), (D) and/or Other Inadmissibility - Specify below 5. List specific reasons for inadmissibility. Form I-690 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 8 Part 2. Additional Information About You (continued) 6. List all immediate relatives in the United States (Parents, spouse, and children). If you need more space, use Part 6. Additional Information or attach an additional sheet. A. Your Relative's Information Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Date of Birth (mm/dd/yyyy) Relationship A-Number (if any) AImmigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status, deferred action recipient) B. Your Relative's Information Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Date of Birth (mm/dd/yyyy) Relationship A-Number (if any) AImmigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status, deferred action recipient) C. Your Relative's Information Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Date of Birth (mm/dd/yyyy) Relationship A-Number (if any) AImmigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status, deferred action recipient) Form I-690 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 8 Part 2. Additional Information About You (continued) D. Your Relative's Information Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Date of Birth (mm/dd/yyyy) Relationship A-Number (if any) AImmigration Status (for example, U.S. citizen, lawful permanent resident, valid nonimmigrant status, deferred action recipient) 7. I should be granted a waiver because: (Describe family unity considerations or humanitarian or public interest reasons for granting a waiver. If you need more space, Part 6. Additional Information or attach a separate sheet of paper; type or print your name and Alien Registration Number (A-Number) (if any), at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. Part 3. Applicant's Statement, Contact Information, Acknowledgement of Appointment at USCIS Application Support Center, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-690 Instructions before completing this part. Applicant's Statement NOTE: Select the box for either Item Number A. or B. If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter A. I can read and understand English, and have read and understand every question and instruction on this application, as well as my answer to every question. I have read and understand the Acknowledgement of Appointment at USCIS Application Support Center. The interpreter named in Part 4. has also read to me every question and instruction on this application, as well as my answer to every question, in , a language in which I am fluent. I understand every question and instruction on this application as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above. The interpreter named in Part 4. has also read the Acknowledgement of Appointment at USCIS Application Support Center to me, in the language in which I am fluent, and I understand this Application Support Center (ASC) Acknowledgement as read to me by my interpreter. 2. Applicant's Statement Regarding the Preparer I have requested the services of and consented to , who is is not an att