Form I-601a - Application For Provisional Unlawful Presence Waiver Page 5
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9Part 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 12/23/16 N
Page 5 of 9
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