Instructions For Form I-601a - Application For Provisional Unlawful Presence Waiver (Page 11 of 21) in pdf

5. American Indian or Alaska Native. A person having origins in any of the original peoples of North and South

America (including Central America), and who maintains tribal affiliation or community attachment.

6. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii,

Guam, Samoa, or other Pacific Islands.

Item Number 3. Height. Select the values that best match your height in feet and inches. For example, if you are five

feet and nine inches, select “5” for feet and “09” for inches. Do not enter your height in meters or centimeters.

Item Number 4. Weight. Enter your weight in pounds. If you do not know your weight, or need to enter a weight under

30 pounds or over 699 pounds, enter “000.” Do not enter your weight in kilograms.

Item Number 5. Eye Color. Select the box that best describes the color of your eyes.

Item Number 6. Hair Color. Select the box that best describes the color of your hair.

Part 3. Information About Your Immigrant Visa Case

In this section, provide information about the approved immigrant visa petition (either Form I-130, Form I-140, or I-360),

and the status of your immigrant visa application at the NVC.

Item Numbers 1.a. - 1.e. Provide the basis on which you are immigrating to the United States (Select only one box).

NOTE: If you are a Diversity Visa (DV) program selectee or derivative, provide the information requested in Item

Numbers 2.a. - 2.d. If you are not filing this application as a Diversity Visa Selectee, skip to Item Number 3.

Item Number 2.a. DOS DV Program Case Number. Provide the DV Case number that was assigned to you (or your

spouse or parent) by the KCC when you (or your spouse or parent) became a DV Program selectee. You can find the

number on your print out from the DV Entrant Status Check page of the DOS Electronic Diversity Visa system website at

Item Numbers 2.b. - 2.d. DV Program Selectee’s Full Name. (If you are not filing this application as a Diversity Visa

Selectee, skip to Item Number 3.) If you are filing as the derivative of a DV program selectee, provide the name of the

principal DV Program selectee (your spouse or your parent).

Item Number 3. If you are (or your spouse or parent) is the beneficiary of an immigrant visa petition filed by a family

member or an employer, provide the information requested in Item Number 3.

Item Number 3.a. USCIS Receipt Number. Provide the receipt number for the approved immigrant visa petition that

was filed on your (or your spouse’s or parent’s) behalf or that you used to self-petition on your behalf. Submit a copy

(if available) of the petition approval notice (Form I-797, Notice of Action). This will assist USCIS in processing your

application for a provisional unlawful presence waiver. Failure to provide a copy of the immigrant visa petition approval

notice may result in processing delays or in the rejection of your application.

NOTE: Failure to provide a copy of the petition approval notice will not, by itself, result in the denial of your application.

Item Number 3.b. DOS Consular Case Number (NVC Case Number). Provide your consular case number (also

called the NVC case number). It is located on your receipt for the DOS immigrant visa processing fee. The NVC case

number must correspond to the approved immigrant visa petition you listed in Part 3., Item Number 3.a.

Item Numbers 3.c. - 3.f. Petitioner’s Full Name and Company or Organization Name. Provide the full name of

the family member or company who filed Form I-130, Form I-140, or Form I-360 on your (or your spouse’s or parent’s)

behalf. If you self-petitioned using Form I-140 or Form I-360, type or print “Self.”

Part 4. Information About Your Qualifying Relative

In this section, provide information about the U.S. citizen or LPR spouse or parent you believe would experience extreme

hardship if you were refused admission to the United States.

Item Numbers l.a. - 2.d. Your Qualifying Relative’s Full Name and Relationship to You. Provide the full name of

your qualifying relative and indicate whether the qualifying relative is your U.S. citizen or LPR spouse or parent.

Form I-601A Instructions 12/23/16 N

Page 11 of 21

Instructions For Form I-601a - Application For Provisional Unlawful Presence Waiver Page 11