Form I-601 - Application For Waiver Of Grounds Of Inadmissibility - U.s. Citizenship And Immigration Services Page 12

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NOTE to the Applicant: If you are approved for a waiver and
Part 11. Statement for Applicants With a Class
after admission to the United States, you fail to comply with the
A Tuberculosis Condition (As Defined By HHS
terms, conditions, and controls that were imposed with the grant
Regulations) (continued)
of the waiver, you may be subject to removal under INA
section 237(a).
Endorsement of State Health Department Official
NOTE: The State Health Department Official in the area
where the applicant plans to reside should complete this
statement.
Endorsement signifies recognition of the local health
department that completed the Statement by Local (City or
County) Health Department section for the purpose of
providing care and treatment of the applicant's tuberculosis
condition, and that the local health department is within your
jurisdiction. Endorsement also signifies recognition that the
applicant will be residing within your state's health jurisdiction.
Endorsed by:
9.a.
Signature of State Health Department Official (sign in ink)
9.b.
Date of Signature (mm/dd/yyyy)
10.
Name of State Health Department
Physical Address
11.a.
Street Number
and Name
11.b.
Apt.
Ste.
Flr.
11.c. City or Town
11.d. State
11.e. ZIP Code
Contact Information
12.
Daytime Telephone Number
13.
Email Address (if any)
NOTE to the Applicant and his or her Sponsor: If you need
assistance, contact USCIS at the National Customer Service
Center at 1-800-375-5283. You may also schedule an
appointment online at Select "Schedule an
Appointment" and follow the screen prompts to set up your
appointment. Once you finish scheduling an appointment, the
system will generate an appointment notice for you.
Form I-601 08/21/17 N
Page 12 of 12

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