USCIS Form I-601A "Application for Provisional Unlawful Presence Waiver"

What Is USCIS Form I-601A?

This is a legal form that was released by the U.S. Department of Homeland Security - Citizenship and Immigration Services on December 15, 2017 and used country-wide. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on December 15, 2017;
  • The latest available edition released by the U.S. Department of Homeland Security - Citizenship and Immigration Services;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of USCIS Form I-601A by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Citizenship and Immigration Services.

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Download USCIS Form I-601A "Application for Provisional Unlawful Presence Waiver"

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USCIS
Application for Provisional Unlawful Presence Waiver
Form I-601A
Department of Homeland Security
OMB No. 1615-0123
U.S. Citizenship and Immigration Services
Expires 07/31/2018
Initial Receipt
Fee Stamp
Action Block
For
USCIS
Use
Resubmitted
Relocated
Only
Received
Sent
To be completed by an
Attorney State Bar Number
Attorney or Accredited Representative
Select this box if
attorney or
Form G-28 is
(if applicable)
USCIS Online Account Number (if any)
attached to represent
BIA-accredited
the applicant.
representative (if any).
START HERE - Type or print in black ink.
Part 1. Information About You
Your U.S. Mailing Address
7.a. In Care Of Name
Provide the following information about yourself.
1.
Alien Registration Number (A-Number) (if any)
A-
7.b.
Street Number
and Name
2.
U.S. Social Security Number (if any)
7.c.
Apt.
Ste.
Flr.
7.d. City or Town
3.
USCIS Online Account Number (if any)
7.e. State
7.f.
ZIP Code
8.
Is your current physical address the same as your mailing
Your Full Name
address?
Yes
No
4.a. Family Name
If you answered "No" to Item Number 8., provide your
(Last Name)
physical address in Item Numbers 9.a. - 9.e.
4.b. Given Name
(First Name)
Your U.S. Physical Address
4.c. Middle Name
9.a.
Street Number
and Name
Other Names Used (if any)
9.b.
Apt.
Ste.
Flr.
5.a. Family Name
(Last Name)
9.c. City or Town
5.b. Given Name
(First Name)
9.d. State
9.e. ZIP Code
5.c. Middle Name
Other Information
6.a. Family Name
(Last Name)
10.
Gender
Male
Female
6.b. Given Name
(First Name)
11.
Date of Birth (mm/dd/yyyy)
6.c. Middle Name
Form I-601A 12/15/17 N
Page 1 of 9
USCIS
Application for Provisional Unlawful Presence Waiver
Form I-601A
Department of Homeland Security
OMB No. 1615-0123
U.S. Citizenship and Immigration Services
Expires 07/31/2018
Initial Receipt
Fee Stamp
Action Block
For
USCIS
Use
Resubmitted
Relocated
Only
Received
Sent
To be completed by an
Attorney State Bar Number
Attorney or Accredited Representative
Select this box if
attorney or
Form G-28 is
(if applicable)
USCIS Online Account Number (if any)
attached to represent
BIA-accredited
the applicant.
representative (if any).
START HERE - Type or print in black ink.
Part 1. Information About You
Your U.S. Mailing Address
7.a. In Care Of Name
Provide the following information about yourself.
1.
Alien Registration Number (A-Number) (if any)
A-
7.b.
Street Number
and Name
2.
U.S. Social Security Number (if any)
7.c.
Apt.
Ste.
Flr.
7.d. City or Town
3.
USCIS Online Account Number (if any)
7.e. State
7.f.
ZIP Code
8.
Is your current physical address the same as your mailing
Your Full Name
address?
Yes
No
4.a. Family Name
If you answered "No" to Item Number 8., provide your
(Last Name)
physical address in Item Numbers 9.a. - 9.e.
4.b. Given Name
(First Name)
Your U.S. Physical Address
4.c. Middle Name
9.a.
Street Number
and Name
Other Names Used (if any)
9.b.
Apt.
Ste.
Flr.
5.a. Family Name
(Last Name)
9.c. City or Town
5.b. Given Name
(First Name)
9.d. State
9.e. ZIP Code
5.c. Middle Name
Other Information
6.a. Family Name
(Last Name)
10.
Gender
Male
Female
6.b. Given Name
(First Name)
11.
Date of Birth (mm/dd/yyyy)
6.c. Middle Name
Form I-601A 12/15/17 N
Page 1 of 9
23.a. Place or Port-of-Entry (Actual or approximate city or town)
Part 1. Information About You (continued)
12.
City or Town of Birth
23.b.
State
13.
Country of Birth
24.a.
From (On or about mm/dd/yyyy)
24.b.
To (On or about mm/dd/yyyy)
14.
Country of Citizenship or Nationality
25.
Immigration Status (At the time of entry)
15.a.
Mother's Family Name (Last Name)
26.
Are there other previous entries?
Yes
No
15.b.
Mother's Given Name (First Name)
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
16.a.
Father's Family Name (Last Name)
provided in Part 9. Additional Information.
Your Immigration or Criminal History
16.b. Father's Given Name (First Name)
27.
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
Your Last Entry Into the United States
DHS officer, or a Federal court yet? (This includes
proceedings under INA section 239, an exclusion or
17.
Date of Entry (On or about mm/dd/yyyy)
deportation proceeding initiated before April 1,1997, a
Visa Waiver Program removal proceeding under INA
section 217, expedited removal under INA 235, and a
18.a.
Place or Port-of-Entry (Actual or approximate city or town)
request for a judicial removal order under INA section
238(c))?
Yes
No
18.b.
State
If you answered “No” to Item Number 27., go to Item
Number 29.a. If you answered “Yes” to Item Number
19.
Immigration Status (At the time of entry)
27., select the statement below (either Item Number
28.a. or 28.b.) that most accurately describes your current
situation.
Your Previous Entries Into the United States
28.a.
I am in removal, exclusion, or deportation
proceedings that are administratively closed and, at
You were previously in the United States as follows:
the time of filing my Form I-601A, have not been
20.a.
Place or Port-of-Entry (Actual or approximate city or town)
placed back on EOIR's calendar to continue my
removal, exclusion, or deportation proceedings.
NOTE: You may be eligible for a provisional
20.b.
State
unlawful presence waiver. Provide a copy of the
administrative closure order. Also, if U.S.
21.a.
From (On or about mm/dd/yyyy)
Citizenship and Immigration Services (USCIS)
approves your provisional unlawful presence
21.b.
To (On or about mm/dd/yyyy)
waiver, you should seek termination or dismissal of
your removal, exclusion, or deportation proceedings
22.
Immigration Status (At the time of entry)
before you depart the United States for your
immigrant visa interview.
Form I-601A 12/15/17 N
Page 2 of 9
31.
Are you currently subject to a grant of voluntary
Part 1. Information About You (continued)
departure that has not expired and that was granted to you
I am currently in removal, exclusion, or deportation
by the immigration judge or the Board of Immigration
28.b.
proceedings that are not administratively closed, or
Appeals during removal, exclusion, or deportation
in removal, exclusion, or deportation proceedings
proceedings?
Yes
No
that were administratively closed, but EOIR has
placed my proceedings back on its calendar in order
NOTE: If you answered "Yes" to Item Number 31., you
to continue them.
are ineligible for a provisional unlawful presence waiver.
NOTE: You are ineligible for a provisional
If you were granted voluntary departure in the past, but
unlawful presence waiver unless your proceedings
then you withdrew your voluntary departure request or
are administratively closed at the time you file your
otherwise terminated voluntary departure you should not
Form I-601A, and the proceedings have not been
select "Yes" to Item Number 31. In this case you may be
put back on EOIR's calendar to continue your
in removal proceedings or you may be the subject of a
removal, exclusion, or deportation after having been
final order of removal, deportation, or exclusion. You
previously administratively closed.
should select the statements that apply to you in Item
Numbers 27. - 28.b. or Item Number 29.a. If you filed
29.a.
Are you currently subject to a final order of removal,
a motion to withdraw your voluntary departure request,
exclusion or deportation? (This includes an order entered
please submit a copy with your Form I-601A.
in proceedings under INA section 239, an exclusion or
deportation order entered in proceedings initiated before
Answer Item Numbers 32. - 38. If you answer "Yes" to any
April 1, 1997, a Visa Waiver Program removal order
question in Item Numbers 32. - 38., your application for a
under INA section 217, an expedited removal order under
provisional unlawful presence waiver may be denied as a matter
INA section 235, and a judicial order under INA section
of discretion. For each "Yes" response for Item Numbers 32. -
238(c))?
Yes
No
38., provide the location and date of the event and a brief
description in Part 9. Additional Information. For Item
NOTE: If you answered "Yes" to Item Number 29.a.,
Number 32., if you were arrested but not charged with any
you are ineligible for a provisional unlawful presence
crime or offense, provide a statement or other documentation
waiver unless you applied for, and USCIS has already
from the arresting authority, prosecutor's office, or court to
approved, an application for permission to reapply for
show that you were not charged with any crime or offense. If
admission under INA section 212(a)(9)(A)(iii) and 8 CFR
you answer "Yes" to Item Number 35., you must provide all
212.2 on Form I-212, Application for Permission to
related court dispositions.
Reapply for Admission into the United States after
Deportation or Removal. If you have already applied for
32.
Have you EVER knowingly and willfully given false or
and if USCIS has already granted you permission to
misleading information to a U.S. Government official
reapply for admission, provide the relevant information in
while applying for an immigration benefit or to gain entry
Item Number 29.b. If you answered "No" to Item
or admission into the United States?
Yes
No
Number 29.a., go to Item Number 31.
33.
Have you EVER been engaged in alien smuggling?
29.b.
USCIS Receipt Number for Your Approved Form I-212:
Yes
No
34.
Have you EVER been arrested, cited, or detained by a
NOTE: You may also provide a copy of the approval
law enforcement officer (including immigration and
notice that USCIS sent to you when it approved your
military officers) in the United States, your home country,
Form I-212.
and/or any other country for any reason other than traffic
30.a. Has DHS served you with a DHS Form I-871, giving you
violations?
Yes
No
notice that DHS intends to reinstate a prior deportation,
exclusion, or removal order against you as permitted
35.
Have you EVER been charged, indicted, convicted,
under INA section 241(a)(5)?
imprisoned, or jailed in the United States, your home
Yes
No
country, and/or any other country for any crime or
30.b.
If you answered "Yes" to Item Number 30.a., has DHS
offense?
Yes
No
served you with a final decision reinstating a prior
deportation, exclusion, or removal order under INA
36.
Have you EVER trafficked in or are you NOW trafficking
section 241(a)(5)?
Yes
No
in any controlled substance?
Yes
No
Form I-601A 12/15/17 N
Page 3 of 9
42.
Have you EVER assisted or participated in selling or
Part 1. Information About You (continued)
providing weapons to any person who to your knowledge
37.
Are you NOW or have you EVER knowingly assisted,
used them against another person, or in transporting
abetted, conspired, or colluded with others in the unlawful
weapons to any person who to your knowledge used them
trafficking of any controlled substance?
against another person?
Yes
No
Yes
No
43.
Have you EVER received any type of military,
38.
Are you NOW or have you EVER been engaged in
paramilitary, or weapons training?
Yes
No
prostitution?
Yes
No
44.
Have you EVER recruited, enlisted, conscripted, or used
any person under 15 years of age to serve in or help an
Answer Item Numbers 39.a. - 45. If you answer "Yes" to any
armed force or group?
question in Item Numbers 39.a. - 45., your application for a
Yes
No
provisional unlawful presence waiver may be denied as a
45.
Have you EVER used any person under 15 years of age
matter of discretion. For each "Yes" response for Item
to take part in hostilities, or to help or provide services to
Numbers 39.a. - 45., provide a complete explanation in
people in combat?
Part 9. Additional Information.
Yes
No
Have you EVER ordered, incited, called for, committed, assisted,
helped with, or otherwise participated in any of the following:
Part 2. Biographic Information
39.a.
Acts involving torture or genocide?
Yes
No
1.
Ethnicity (Select only one box)
39.b. Killing any person?
Yes
No
Hispanic or Latino
39.c.
Intentionally and severely injuring any person?
Not Hispanic or Latino
Yes
No
2.
Race (Select all applicable boxes)
39.d.
Engaging in any kind of sexual contact or relations with
White
any person who was being forced or threatened?
Asian
Yes
No
Black or African American
39.e.
Limiting or denying any person's ability to exercise
American Indian or Alaska Native
religious beliefs?
Yes
No
Native Hawaiian or Other Pacific Islander
Have you EVER:
3.
Height
Feet
Inches
40.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, self-
4.
Weight
Pounds
defense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
5.
Eye Color (Select only one box)
Yes
No
Black
Blue
Brown
40.b.
Served in any prison, jail, prison camp, detention facility,
Gray
Green
Hazel
labor camp, or any other situation that involved detaining
persons?
Maroon
Pink
Unknown/Other
Yes
No
6.
Hair Color (Select only one box)
41.
Have you EVER been a member of, assisted in, or
participated in any group, unit, or organization of any
Bald (No hair)
Black
Blond
kind in which you or other persons used any type of
Brown
Gray
Red
weapon against any person or threatened to do so?
Sandy
White
Unknown/
Yes
No
Other
Form I-601A 12/15/17 N
Page 4 of 9
Part 3. Information About Your Immigrant
Part 4. Information About Your Qualifying
Visa Case
Relative
Provide the basis on which you are immigrating to the United
Provide the following information about the qualifying relative
States using the check boxes below. (Select only one box)
(the U.S. citizen or Lawful Permanent Resident (LPR) spouse or
parent) who would experience extreme hardship if you were
1.a.
Diversity Visa Program Selectee or Derivative
refused admission to the United States.
1.b.
Immediate Relative Petition (Form I-130)
Your Qualifying Relative's Full Name and
1.c.
Preference-Based Family Petition (Form I-130),
Relationship to You
including Derivatives
1.a. Family Name
1.d.
Employment-Based Petition (Form I-140), including
(Last Name)
Derivatives
1.b. Given Name
1.e.
Special Immigrant/Widow Petition (Form I-360),
(First Name)
including Derivatives
1.c. Middle Name
If you selected Item Number 1.a. because you are a Diversity
2.a.
U.S. Citizen Spouse
Visa (DV) Program selectee or derivative, provide information
about your (or your spouse's or parent's) DV case:
2.b.
U.S. Citizen Parent
2.a.
DOS DV Case Number (KCC Case Number)
2.c.
LPR Spouse
2.d.
LPR Parent
DV Program Selectee's Full Name (If you are a derivative and
your parent or spouse is the DV Program Selectee)
Your Other Qualifying Relative
2.b. Family Name
3.
Do you have more than one qualifying relative (U.S. citizen
(Last Name)
or LPR spouse or parent)?
Yes
No
2.c. Given Name
(First Name)
If you answered "Yes" to Item Number 3., provide the
2.d. Middle Name
other qualifying relative's name and your relationship to
the qualifying relative in Item Numbers 4.a. - 5.d.
If you selected Item Numbers 1.b., 1.c., 1.d., or 1.e. provide
Also provide evidence of the U.S. citizenship or LPR
the following information about the approved immigrant visa
status of the other qualifying relative with your
petition (Form I-130, Form I-140, or Form I-360) that was filed
application. See the What Evidence Must I Submit
on your (or your spouse's or parent's) behalf, or that you used to
With Form I-601A section of the Instructions.
self-petition on your behalf, that is your basis to immigrate and
the related Department of State (DOS) immigrant visa
Additional Qualifying Relative's Full Name and
application.
Relationship to You
3.a.
USCIS Receipt Number
4.a. Family Name
(Last Name)
4.b. Given Name
3.b.
DOS Consular Case Number (NVC Case Number)
(First Name)
4.c. Middle Name
Petitioner Name (Provide the full name of the family member or
5.a.
U.S. Citizen Spouse
the company who petitioned for you (or your spouse or parent).)
5.b.
U.S. Citizen Parent
3.c. Family Name
(Last Name)
5.c.
LPR Spouse
3.d. Given Name
5.d.
LPR Parent
(First Name)
3.e. Middle Name
3.f.
Company or Organization Name
Form I-601A 12/15/17 N
Page 5 of 9