Application for Waiver of Grounds of Inadmissibility Department of Homeland Security U.S. Citizenship and Immigration Services Fee Stamp For USCIS Use Only Benefits Category Immigrant V Nonimmigrant Adjustment of Status K Nonimmigrant 212(a)(3) 212(a)(4) 212(a)(6) 212(a)(9) 212(a)(10) Other TPS USCIS Form I-601 OMB No. 1615-0029 Expires 03/31/2017 Initial Receipt Resubmitted Action Block Relocated Received Sent Inadmissible Under 212(a)(1) 212(a)(2) 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 1. Alien Registration Number (A-Number) (if any) Mailing Address NOTE: If you are outside of the United States, provide a U.S. mailing address, if available. If a U.S. mailing address is not available, provide your mailing address abroad. 5.a. In Care Of Name A2. USCIS Online Account Number (if any) Your Full Name 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 5.b. Street Number and Name 5.c. Apt. Ste. Flr. 5.d. City or Town 5.e. State 5.g. Province 5.h. Postal Code 5.i. Country 5.f. ZIP Code Other Names Used List all other names you have ever used, including maiden names, aliases, and nicknames. If you need extra space to complete this section, use the space provided in Part 10. Additional Information. 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 6. Is your mailing address the same address where you currently live (physical address)? Yes No If your mailing address and the address where you currently live (physical address) are not the same, provide your current physical address in the next section. Form I-601 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 13 Part 1. Information About You (continued) Physical Address 7.a. Street Number and Name 7.b. Apt. Ste. Flr. 16.a. Are you filing this application after you have already filed Form I-485, Application to Register Permanent Residence or Adjust Status? Yes No 16.b. If you answered "Yes" to Item Number 16.a., provide the USCIS Receipt Number for your Form I-485. 7.c. City or Town 7.d. State 7.f. Province 7.e. ZIP Code 17.a. Are you filing this application after you have already filed Form I-821, Application for Temporary Protected Status? Yes No 17.b. If you answered "Yes" to Item Number 17.a., provide the USCIS Receipt Number for your Form I-821, if any. 7.g. Postal Code 7.h. Country 18.a. Have you previously filed Form I-212, Application for Permission to Reapply for Admission into the United States After Deportation or Removal? Yes No 18.b. If you answered "Yes" to Item Number 18.a., provide the USCIS Receipt Number for your Form I-212, if any. Other Information 8. U.S. Social Security Number (if any) 18.c. Where did you file your application (for example, USCIS Office, U.S. Port-of-Entry, Immigration Court)? 9. 10. 11. Gender Male Female 18.d. Date Filed (mm/dd/yyyy) 19. Are you submitting Form I-212 along with this application? Yes No Date of Birth (mm/dd/yyyy) City or Town of Birth 12. Province of Birth (if applicable) Part 2. U.S. Entry Information 13. Country of Birth Provide information for your previous periods of stay in the United States, beginning with your most recent arrival date. NOTE: If you need extra space to complete this section, use the space provided in Part 10. Additional Information. 1.a. Date you entered the U.S. (mm/dd/yyyy) If you seek a visa and you were already interviewed by a U.S. Department of State (DOS) consular officer at a U.S. Embassy or U.S. Consulate, provide the information requested in Item Numbers 15.a. - 15.b. 15.a. DOS Consular Case Number (if available) 14. Country of Citizenship or Nationality 1.b. Immigration status at the time of your entry into the U.S. 1.c. Location at which you entered the U.S. 15.b. The location of the U.S. Embassy or U.S. Consulate where your visa application is being or will be made City 1.d. U.S. city or town where you lived Country 2.a. Date you entered the U.S. (mm/dd/yyyy) 2.b. Date you departed the U.S. (mm/dd/yyyy) Form I-601 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 13 Part 2. U.S. Entry Information (continued) 2.c. Immigration status at the time of your entry into the U.S. If you are seeking a waiver of inadmissibility because you have a Class A Tuberculosis condition (as defined by U.S. Department of Health and Human Services (HHS) regulations), you must complete Part 11. of this application. If you are seeking a waiver of inadmissibility because you have a history of physical or mental disorders, you must attach the information requested in the instructions. 2.d Location at which you entered the U.S. 2.e. U.S. city or town where you lived Section A I am an applicant for an immigrant visa or adjustment of status (other than based on T nonimmigrant status or based on classification as a Special Immigrant Juvenile, see Section B below), or for K or V nonimmigrant status, and I believe or I was told that I am inadmissible because (review the application instructions for a detailed explanation of the individual grounds of inadmissibility listed below): Select all grounds that you believe apply to you. 1. I have a communicable disease of public health significance. (A list of communicable diseases of public health significance can be found in the Specific Instructions section of the application instructions.) I seek an exemption from the vaccination requirement because vaccinations are against my religious beliefs or moral convictions. I have or had a physical or mental disorder and behavior (or history of behavior that is likely to recur) associated with the disorder, which has posed or may pose a threat to the property, safety, or welfare of myself or others. I have been involved in a crime of moral turpitude (other than a purely political offense). I have been involved in a controlled substance violation according to the laws and regulations of any state, the United States, or a foreign country related to a single offense of simple possession of 30 grams or less of marijuana. I have been convicted of two or more offenses (other than purely political offenses), for which the combined sentences to confinement were five years or more. I am coming to the U.S. to engage in prostitution or, in the past 10 years, I