Application for Provisional Unlawful Presence Waiver

• Legal Form Number: I-601A
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Page 1 of 9Form I-601A Edition 08/31/21

Application for Provisional Unlawful Presence Waiver

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-601A

OMB No. 1615-0123

Expires 08/31/2023

Fee Stamp

For

USCIS

Use

Only Relocated

Action Block

SentReceived

Initial Receipt

Resubmitted

START HERE - Type or print in black ink.

►

Select this box if

Form G-28 is

attached to represent

the applicant.

Attorney State Bar Number

(if applicable) Attorney or Accredited Representative

USCIS Online Account Number (if any)

To be completed by an

attorney or

BIA-accredited

representative (if any).

►

Part 1. Information About You

Alien Registration Number (A-Number) (if any)1.

U.S. Social Security Number (if any)

►A-

Provide the following information about yourself.

2.

►

3. USCIS Online Account Number (if any)

Your Full Name

4.a. Family Name

(Last Name)

4.b. Given Name

(First Name)

4.c. Middle Name

Other Names Used (if any)

5.a. Family Name

(Last Name)

5.b. Given Name

(First Name)

5.c. Middle Name

6.a. Family Name

(Last Name)

6.b. Given Name

(First Name)

6.c. Middle Name

Your U.S. Mailing Address

Street Number

and Name

7.a.

In Care Of Name

7.b.

7.c. Apt. Ste. Flr.

7.d. City or Town

7.e. State 7.f. ZIP Code

10.

9.d. State 9.e. ZIP Code

9.c. City or Town

Street Number

and Name

9.a.

9.b. Flr.Ste.Apt.

If you answered "No" to Item Number 8., provide your

physical address in Item Numbers 9.a. - 9.e.

8. Is your current physical address the same as your mailing

address?

Gender Male Female

Yes No

Other Information

Your U.S. Physical Address

11. Date of Birth (mm/dd/yyyy)

(USPS ZIP Code Lookup)