Form I-191 - Application For Relief Under Former Section 212(C) Of The Immigration And Nationality Act (Ina) Page 3

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Part 1. Information About You (continued)
15.
Information About Your Departures From and Returns To the United States
Since being admitted as an LPR, you have departed from and returned to the United States as follows:
Departed From The United States
Date of Departure
Place or Port-of-Departure
Means of Transportation
(mm/dd/yyyy)
Returned To The United States
Date of Entry
Place or Port-of-Entry
Means of Transportation
(mm/dd/yyyy)
Purpose of Trips
Form I-191 12/23/16 N
Page 3 of 17

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