Fee Stamp
For
USCIS
Use
Only
Resubmitted
Action Block
Relocated
Received
Sent
Benefits Category
Immigrant
USCIS
Form I-601
Adjustment of Status
V Nonimmigrant
TPS
K Nonimmigrant
Inadmissible Under
212(a)(1)
212(a)(3)
212(a)(6)
212(a)(10)
212(a)(2)
212(a)(4)
212(a)(9)
Other
To be completed
by an Attorney
or Accredited
Representative (if any).
Mailing Address
1.
2.
5.c.
5.e. State
Apt.
Ste.
Flr.
ZIP Code
5.g. Province
List all other names you have ever used, including maiden names,
aliases, and nicknames. If you need extra space to complete this
section, use the space provided in Part 10. Additional
Information.
Country
6.
If your mailing address and the address where you currently live
(physical address) are not the same, provide your current
physical address in the next section.
Page 1 of 13
Physical Address
16.a. Are you filing this application after you have already filed
Form I-485, Application to Register Permanent Residence
or Adjust Status?
Yes
No
7.b.
Apt.
Ste.
Flr.
17.a. Are you filing this application after you have already filed
Form I-821, Application for Temporary Protected Status?
Yes
No
17.b. If you answered "Yes" to Item Number 17.a., provide
the USCIS Receipt Number for your Form I-821, if any.
Province
7.h. Country
Other Information
8.
9.
Gender
Male
10.
11.
12.
18.c. Where did you file your application (for example, USCIS
Office, U.S. Port-of-Entry, Immigration Court)?
Female
18.d. Date Filed (mm/dd/yyyy)
19.
Country of Birth
14.
1.b. Immigration status at the time of your entry into the U.S.
City
Country
Page 2 of 13
2.d
Section A
2.
2.
3.
4.
5.
6.
7.
8.
Height
Feet
4.
Weight
Pounds
5.
6.
Inches
Black
Blue
Brown
Gray
Green
Maroon
Pink
Hazel
Unknown/Other
Black
Gray
White
Blond
Red
Unknown/
Other
Page 3 of 13
Section B
9.
10.
19.
11.
12.
13.
14.
15.
16.
17.
18.
Section C
I am applying for TPS and I believe or I was told that I am
inadmissible because:
Select all grounds that you believe, according to the best of your
knowledge, or that you were told apply to you.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Other (specify):
Page 4 of 13
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
Other (specify):
40.
Page 5 of 13
6.
7.
8.
Physical Address
2.a. Street Number
and Name
2.b.
Apt.
Ste.
Flr.
Province
Contact Information
3.
4.
Other Information
5.
Page 6 of 13
Apt.
Ste.
Flr.
Province
Contact Information
3.
4.
Other Information
5.
Applicant's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
6.
7.
8.
1.a.
1.b.
,
a language in which I am fluent. I understand every
question and instruction on this application as
translated to me by my interpreter, and have provided
complete, true, and correct responses in the language
indicated above. The interpreter named in Part 8. has
also read the Acknowledgement of Appointment at
USCIS Application Support Center to me, in the
language in which I am fluent, and I understand this
Application Support Center (ASC) Acknowledgement
as read to me by my interpreter.
Page 7 of 13
Applicant's Certification
,
who
is
is not an attorney or accredited
representative, preparing this application for me. This
person who assisted me in preparing my application
has reviewed the Acknowledgement of Appointment
at USCIS Application Support Center with me, and
I understand the ASC Acknowledgement.
4.
Applicant's Signature
6.a. Applicant's Signature
5.
2.
Page 8 of 13
Interpreter's Signature
6.a. Interpreter's Signature
Apt.
Flr.
Province
3.h. Country
4.
5.
I certify that:
3.b.
,
I am fluent in English and
which is the same language provided in Part 7., Item Number
1.b.;
Apt.
Ste.
Flr.
3.f.
3.h. Country
Province
4.
5.
6.
Page 9 of 13
7.b.
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this application on behalf of, at the
request of, and with the express consent of the applicant. I
completed this application based only on responses the
applicant provided to me. After completing the application, I
reviewed it and all of the applicant's responses with the
applicant, who agreed with every answer on the application. If
the applicant supplied additional information concerning a
question on the application, I recorded it on the application. I
have also read the Acknowledgement of Appointment at
USCIS Application Support Center to the applicant and the
applicant has informed me that he or she understands the ASC
Acknowledgement.
Preparer's Signature
8.a. Preparer's Signature
Page 10 of 13
5.d.
1.a
Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.
3.d.
6.d.
4.d.
Page 11 of 13
Physical Address
4.a. Street Number
and Name
4.b.
Apt.
Ste.
Flr.
Statement by Applicant
Upon admission to the United States, I will go directly to the
health department named in the section below; present all Xrays used in the visa medical examination to substantiate
diagnosis; submit to such examinations, treatment, isolation,
and medical regimen as may be required; and remain under the
prescribed treatment or observation, whether on an inpatient or
outpatient basis, until discharged.
1.a. Signature of Applicant
4.d. State
Physician's Certification
5.a. Signature of Physician
6.
7.
2.b.
3.
Apt.
Ste.
Flr.
Page 12 of 13
Physical Address
11.a. Street Number
and Name
11.b.
Apt.
Ste.
Flr.
Contact Information
12.
13.
Page 13 of 13