Application for Waiver of Passport and/or Visa

• Legal Form Number: I-193
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

OMB No. 1651-0107

Expires 11/30/2017

APPLICATION FOR WAIVER

OF PASSPORT AND/OR VISA

FEE STAMP

FILE NUMBER

1. MY NAME IS: (LAST) (FIRST) (MIDDLE)

2. MY UNITED STATES DESTINATION IS: (NUMBER AND STREET, APT. NO., CITY, STATE, ZIP CODE)

3. MY PERMANENT ADDRESS ABROAD IS:

4. THE COUNTRY OF WHICH I AM A CITIZEN, SUBJECT OR NATIONAL IS:

5. PLACE OF BIRTHDATE OF BIRTH (MM/DD/YYYY):

6. DATE OF ARRIVAL:PORT OF ARRIVAL:

7. MANNER OF ARRIVAL (NAME OF VESSEL, AIRLINE, ETC.)

8. PLACE VISA PREVIOUSLY ISSUED:DATE:NUMBER:CLASSIFICATION:VALID TO:

9. PLACE PASSPORT ISSUED: DATE:NUMBER:VALID TO:

10. THE REASON I AM NOT IN POSSESSION OF PASSPORTVISAIS AS FOLLOWS:(CONTINUE ON REVERSE, IF NECESSARY)

DATE OF THIS APPLICATION: I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT.

SIGNATURE OF APPLICANT

SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT.

I DECLARE THAT THIS 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

APPLICANT - DO NOT WRITE BELOW THIS LINE

APPLICATION APPROVED. WAIVER GRANTED APPLICATION DISAPPROVED.

UNDER SECTION 211(b)

BY AUTHORITY OF (DHS)

UNDER SECTION 212(d)(4)

BY AUTHORITY OF (DHS)

ADMITTED AS UNTIL

NONIMMIGRANT CLASS

DHS Form I-193 (12/14)

CITY AND STATE:

DATE

OF

ACTION

DFO

OR

PD

OFFICE

DEPARTMENT OF HOMELAND SECURITY