Form I-601 - Application For Waiver Of Grounds Of Inadmissibility - U.s. Citizenship And Immigration Services Page 3
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12If you are seeking a waiver of inadmissibility because you have
Part 2. U.S. Entry Information (continued)
a Class A Tuberculosis condition (as defined by U.S.
2.b. Date You Departed the U.S. (mm/dd/yyyy)
Department of Health and Human Services (HHS) regulations),
you must complete Part 11. of this application.
If you are seeking a waiver of inadmissibility because you have
2.c. Immigration Status At the Time of Your Reentry Into the U.S.
a history of physical or mental disorders, you must attach the
information requested in the instructions.
2.d
Location at Which You Entered the U.S.
Section A
I am an applicant for an immigrant visa or adjustment of
2.e. U.S. City or Town Where You Lived
status (other than based on T nonimmigrant status or based
on classification as a Special Immigrant Juvenile, see Section
B below), or for K or V nonimmigrant status, and I believe
or I was told that I am inadmissible because (review Form
Part 3. Biographic Information (for USCIS
I-601 Instructions for a detailed explanation of the individual
Applicant only)
grounds of inadmissibility listed below):
1.
Ethnicity (Select only one box)
Select all grounds that you believe apply to you.
Hispanic or Latino
1.
I have a communicable disease of public health
Not Hispanic or Latino
significance. (A list of communicable diseases of
public health significance can be found in the Specific
2.
Race (Select all applicable boxes)
Instructions section of Form I-601 Instructions.)
White
I seek an exemption from the vaccination requirement
2.
Asian
because vaccinations are against my religious beliefs
Black or African American
or moral convictions.
American Indian or Alaska Native
I have or had a physical or mental disorder and
3.
Native Hawaiian or Other Pacific Islander
behavior (or history of behavior that is likely to recur)
associated with the disorder, which has posed or may
3.
Height
Feet
Inches
pose a threat to the property, safety, or welfare of
myself or others.
4.
Weight
Pounds
4.
I have been involved in a crime of moral turpitude
5.
Eye Color (Select only one box)
(other than a purely political offense).
Black
Blue
Brown
5.
I have been involved in a controlled substance
violation according to the laws and regulations of any
Gray
Green
Hazel
state, the United States, or a foreign country related
Maroon
Pink
Unknown/Other
to a single offense of simple possession of 30 grams
6.
Hair Color (Select only one box)
or less of marijuana.
Bald (No hair)
Black
Blond
6.
I have been convicted of two or more offenses (other
than purely political offenses), for which the combined
Brown
Gray
Red
sentences to confinement were five years or more.
Sandy
White
Unknown/
7.
I am coming to the U.S. to engage in prostitution or,
Other
in the past 10 years, I have engaged in prostitution
(including receiving the proceeds of, in full or in
Part 4. Reasons for Inadmissibility
part), procurement of prostitution, or I continue to
engage in prostitution or procurement of prostitution.
Select all of the following grounds that you believe, according to
the best of your knowledge, or that you were told, apply to you.
8.
In the past 10 years, I have (either directly or
Only select the applicable grounds listed under the immigration
indirectly) procured, attempted to procure, or to
benefit you are seeking.
import prostitutes or persons for the purpose of
prostitution.
If you were ever arrested or convicted, provide the disposition
(outcome) for all arrests or convictions (for example, dismissed
from the appropriate authority). You also will be required to
provide certified court records or dispositions for all convictions.
Form I-601 08/21/17 N
Page 3 of 12
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