Form I-191 - Application For Advance Permission To Return To Unrelinquished Domicile
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2OMB No. 1615-0016
I-191, Application for Advance Permission
Department of Homeland Security
to Return to Unrelinquished Domicile
U.S. Citizenship and Immigration Services
Fee Stamp
Action Block
Alien Registration Number
Date
(1) I hereby apply for permission to return to the United States under the authority contained in Section 212(c) of the Immigration and Nationality Act.
MY NAME IS:
(First)
(Middle)
(Last)
DATE OF BIRTH: (mm/dd/yyyy)
PLACE OF BIRTH: (City, Province, Country)
I AM A CITIZEN/NATIONAL OF: (Country)
PRESENT ADDRESS: (Street and number, apt. no., city, state, country)
(2) I was lawfully admitted to the United States for permanent residence at:
PORT OF ENTRY/DHS OFFICE:
DATE: (mm/dd/yyyy)
NAME OF VESSEL OR OTHER MEANS OF CONVEYANCE:
(3) Since that admission I have departed from and reentered the United States as follows:
DEPARTED FROM THE UNITED STATES
RETURNED TO THE UNITED STATES
PURPOSE OF TRIP
Date
Date
Vessel or Other Means
Vessel or Other Means
Port
Port
(mm/dd/yyyy)
(mm/dd/yyyy)
of Conveyance
of Conveyance
(4) During the past 7 years I have resided at the following places: (List present address first)
(Complete Address - Include Apt. No.)
From -
To-
Present time
(5) During the past 7 years I have been employed as follows: (List present employment first)
Occupation or Type of
From -
To -
Employer's Name
Address
Business
(6) My immediate family (spouse, unmarried minor children and parents) consists of the following persons:
Name
Relation
Date and Country of Birth
Citizen of
Present Address
(7) I
depart(ed) temporarily from the United States on or about
and will remain
(Intend to or have)
(Date - mm/dd/yyyy)
in
approximately
, for the purpose of
(Country)
(Length of Time)
; and expect to apply for admission at
(Port)
Remarks:
RECEIVED
TRANS. IN
RET'D-TRANS. OUT
COMPLETED
Form I-191 (Rev. 04/08/11) Y
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