OMB No. 1615-0069; Exp. 01/31/12
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.
First Name
Middle Name
A-Number
Family Name (in capital letters)
City or Town
State
Zip Code
Present Address:
Number and Street
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
Date:
Applicant's Signature:
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:
USCIS Field Office
Date of Action
USCIS Office Director
Form I-602 (Rev. 01/06/10)Y