Form I-601a - Application For Provisional Unlawful Presence Waiver
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9USCIS
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 12/23/16 N
Page 1 of 9
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