Form I-601a - Application For Provisional Unlawful Presence Waiver Page 6
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9Part 6. Applicant's Statement, Contact
Part 5. Statement From Applicant
Information, Certification, and Signature
In the space provided, explain in detail why you believe USCIS
should approve your application for a provisional unlawful
NOTE: Read the Penalties section of the Form I-601A
presence waiver as a matter of discretion. Provide all of the
Instructions before completing this part. You must file Form
reasons you believe support your application for this waiver,
I-601A while in the United States.
including information about the extreme hardship your
qualifying relatives would experience if you were refused
Applicant's Statement
admission to the United States. If you need extra space to
complete your statement, use the space provided in Part 9.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
Additional Information.
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
The interpreter named in Part 7. read to me every
1.b.
question and instruction on this application and my
answer to every question in
,
a language in which I am fluent, and I understood all
of this information as interpreted.
2.
At my request, the preparer named in Part 8.,
,
prepared this application for me based only upon
information I provided or authorized.
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
Applicant's Certification
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any of my records that USCIS may need to determine my
eligibility for the immigration benefit I seek.
I further authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
Form I-601A 12/23/16 N
Page 6 of 9
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