Form I-191 - Application For Advance Permission To Return To Unrelinquished Domicile Page 2

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(8) I believe I may be inadmissible to the United States for the following reasons:

I understand that the information herein contained may be used in any criminal or civil proceedings, including removal, hereafter instituted against me.

I certify that the statements above are true and correct to the best of my knowledge and belief.

(Signature of Applicant)

Signature of person preparing form, if other than applicant.

I declare that the document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.

(Signature)

(Address)

(Date)

Decision:

DATE

Application granted upon the following terms and conditions:

ACTION

DISTRICT