Form I-601 - Application For Waiver Of Grounds Of Inadmissibility - U.s. Citizenship And Immigration Services Page 5

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40.
Part 4. Reasons for Inadmissibility (continued)
29.
I have sought to procure an immigration benefit by
fraud or by concealing or misrepresenting a material
fact (immigration fraud or misrepresentation).
30.
I falsely represented myself as a U.S. citizen.
31.
I have been engaged in alien smuggling.
32.
I am subject to a civil penalty because I have been the
subject of a final order for violation of INA section
274C.
33.
I am ineligible for U.S. citizenship because I departed
from or remained outside the United States to avoid
or evade training or service in the armed forces in a
time of war or national emergency.
34.
I have practiced polygamy since I entered the United
States or I intend to practice polygamy in the United
States.
35.
I am accompanying another alien who is inadmissible
after being certified to be helpless under INA section
232(c) and I am inadmissible because that other alien
requires my protection or guardianship.
36.
I have detained, retained, or withheld the custody of a
child having a lawful claim to U.S. citizenship, outside
the United States, from a person granted custody.
37.
I was an unlawful voter who voted in violation of a
Federal, state, or local constitutional provision, statute,
ordinance, or regulation.
38.
I am a former U.S. citizen who renounced my
citizenship in order to avoid taxation by the United
States.
39.
Other (specify):
Your Inadmissibility Statement
In the space provided in Item Number 40., provide a statement
and a full explanation of the acts, convictions, and/or medical
conditions that you believe or you were told make you
inadmissible.
Your statement must indicate when you engaged in the acts that
you believe make you inadmissible, the date of all convictions,
or the date of any medical diagnosis. You must provide this
information even if the information is also in the documents that
you submit with your application.
If you need extra space to complete your statement, use the
space provided in Part 10. Additional Information or attach a
separate letter. If you include a separate letter, indicate in Item
Number 39. that you are attaching a letter.
Form I-601 08/21/17 N
Page 5 of 12

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