Application for Relief Under Former Section 212(c) of the Immigration and Nationality Act (INA)

• Legal Form Number: I-191
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-191 Edition 07/20/21 Page 1 of 19

To be completed by an

Attorney or Accredited

Representative (if any).

Application for Relief Under Former Section 212(c)

of the Immigration and Nationality Act (INA)

Department of Homeland Security

U.S. Citizenship and Immigration Services

For

USCIS

Use

Only

USCIS

Form I-191

OMB No. 1615-0016

Expires 11/30/2023

Part 1. Information About You

START HERE - Type or print in black ink.►

Family Name (Last Name) Given Name (First Name) Middle Name

Your Full Legal Name1.

Middle Name Given Name (First Name)Family Name (Last Name)

Other Names Used2.

The individual applying for relief under former Immigration and Nationality Act (INA) section 212(c) completes this section.

Action BlockDate Fee Stamp

Attorney State Bar Number

(if applicable)

Select this box if

Form G-28 is

attached.

Attorney or Accredited Representative

USCIS Online Account Number (if any)

RECEIVED COMPLETEDRETD/TRANS OUT

TRANS IN

Provide any other names you have used at any time since birth, including aliases, maiden names, and nicknames. If you need

extra space to complete this section, use the space provided in Part 12. Additional Information.

In Care Of Name (if any)

Postal Code

City or Town State ZIP Code

Street Number and Name Apt. Flr. NumberSte.

CountryProvince

Current Mailing Address3.

Is your current mailing address the same as your physical address?4. Yes No

NOTE: If you answered "No" to Item Number 4., provide your physical address below.

Form I-191 Edition 07/20/21 Page 2 of 19

6. 7.Date of Birth (mm/dd/yyyy)

8.

Place of Birth

City/Town/Village of Birth

Country of Birth

State/Province of Birth

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

►A-

10.

USCIS Online Account Number (if any)

►

9. Your Country of Citizenship or Nationality

Part 1. Information About You (continued)

5. Current Physical Address (if different from the address above)

City or Town State ZIP Code

Street Number and Name Apt. Flr. NumberSte.

Postal Code CountryProvince

In Care Of Name (if any)

Other Information

List the country where you are currently a citizen or national. If you need extra space to complete this item, use the space

provided in Part 12. Additional Information.

List the city/town/village, state/ province, and country where you were born.

Admission with an Immigrant Visa at a Port of Entry (Complete Item Number 12.)

Adjustment of Status Granted by USCIS While in the United States (Complete Item Number 13.)

11. Information About Your Lawful Permanent Resident (LPR) Status

A.

B.

Date You Obtained Your LPR Status (mm/dd/yyyy)

How You Obtained Your LPR Status (select only one box)

Adjustment of Status Granted by Immigration Judge or Board of Immigration Appeals While Inside the United States

(Complete Item Number 14.)

If you selected “Admission with an Immigrant Visa at a Port of Entry,” provide the information requested below.12.

Port-of-Entry City or Town

Means of Transportation

Port-of-Entry State