Form I-602 - Application By Refugee For Waiver Of Grounds Of Excludability
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4OMB No. 1615-0069; Exp. 12/31/2018
I-602, Application by Refugee for
Department of Homeland Security
Waiver of Grounds of Excludability
U.S. Citizenship and Immigration Services
To be completed by all applicants (Type or print in black ink)
PART 1.
Family Name (in capital letters)
First Name
Middle Name
A-Number
Present Address:
Number and Street
City or Town
State
ZIP Code
Date of Birth
Place of Birth
Country of Birth
(mm/dd/yyyy)
(City or Town)
Country of Citizenship
PART 2.
I have been declared inadmissible or ineligible for adjustment of status under the following section(s) of 212(a) of the Immigration
and Nationality Act (INA). (NOTE: Sections 212(a)(4), 212(a)(5), and 212(a)(7)(A) do not apply to refugees under Sections 207
or 209 of the INA.)
I am inadmissible because: (List the specific acts, convictions, or physical or mental conditions. If you have active or suspected
tuberculosis, fully complete Part 3 on Page 2. If you have, or have had, a physical or mental disorder, and behavior associated with
the disorder that may pose, or has posed, a threat to the property, safety, or welfare of you or others, complete Part 3A on Page 2.)
I request a waiver of the grounds inadmissibility listed above for the following reasons: (Check the appropriate block and explain below)
For humanitarian reasons
To assure family unity
In the public interest
Applicant's Signature:
Date:
Do not write below this line (For USCIS Use Only)
Waiver of grounds of inadmissibility is granted.
Waiver of grounds of inadmissibility is denied. Basis for Denial:
Date of Action
USCIS Office Director
USCIS Field Office
Form I-602 (Rev. 12/19/16) Y Page 1
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