Form I-191 - Application For Relief Under Former Section 212(C) Of The Immigration And Nationality Act (Ina)

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Application for Relief Under Former Section 212(c)
of the Immigration and Nationality Act (INA)
USCIS
Form I-191
Department of Homeland Security
OMB No. 1615-0016
U.S. Citizenship and Immigration Services
Expires 09/30/2018
Date
Fee Stamp
Action Block
For
USCIS
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Only
RECEIVED
TRANS IN
RETD/TRANS OUT
COMPLETED
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
To be completed by an
Form G-28 is
(if applicable)
USCIS Online Account Number (if any)
attorney or accredited
attached.
representative (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)
►
A-
5.
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
Page 1 of 17

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