Form I-601 - Application For Waiver Of Grounds Of Inadmissibility - U.s. Citizenship And Immigration Services Page 2

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16.a.
Are you filing this application after you have already filed
Part 1. Information About You (continued)
Form I-485, Application to Register Permanent Residence
or Adjust Status?
Yes
No
Physical Address
7.a.
Street Number
16.b. If you answered "Yes" to Item Number 16.a., provide
and Name
the USCIS Receipt Number for your Form I-485.
►
7.b.
Apt.
Ste.
Flr.
17.a. Are you filing this application after you have already filed
7.c. City or Town
Form I-821, Application for Temporary Protected Status?
Yes
No
7.d. State
7.e. ZIP Code
17.b.
If you answered "Yes" to Item Number 17.a., provide
7.f.
Province
the USCIS Receipt Number for your Form I-821, if any.
►
7.g. Postal Code
18.a.
Have you previously filed Form I-212, Application for
7.h. Country
Permission to Reapply for Admission into the United
States After Deportation or Removal?
Yes
No
18.b. If you answered "Yes" to Item Number 18.a., provide
Other Information
the USCIS Receipt Number for your Form I-212, if any.
►
8.
U.S. Social Security Number (if any)
►
18.c. Where did you file your application (for example, USCIS
Office, U.S. Port-of-Entry, Immigration Court)?
9.
Gender
Male
Female
10.
Date of Birth (mm/dd/yyyy)
18.d. Date Filed (mm/dd/yyyy)
11.
City or Town of Birth
19.
Are you submitting Form I-212 along with this application?
Yes
No
12.
Province of Birth (if applicable)
Part 2. U.S. Entry Information
13.
Country of Birth
Provide information for your previous periods of stay in the
United States, beginning with your most recent arrival date.
NOTE: If you need extra space to complete this section, use
14.
Country of Citizenship or Nationality
the space provided in Part 10. Additional Information.
1.a. Date You Entered the U.S. (mm/dd/yyyy)
If you seek a visa and you were already interviewed by a U.S.
Department of State (DOS) consular officer at a U.S. Embassy
or U.S. Consulate, provide the information requested in Item
1.b.
Immigration Status At the Time of Your Entry Into the U.S.
Numbers 15.a. - 15.b.
15.a. DOS Consular Case Number (if available)
1.c.
Location at Which You Entered the U.S.
15.b.
The location of the U.S. Embassy or U.S. Consulate where
1.d. U.S. City or Town Where You Lived
your visa application is being or will be made
City
2.a. Date You Entered the U.S. (mm/dd/yyyy)
Country
Form I-601 08/21/17 N
Page 2 of 12

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