Form I-601a - Application For Provisional Unlawful Presence Waiver Page 2
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923.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 12/23/16 N
Page 2 of 9
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