Form I-601 - Application For Waiver Of Grounds Of Inadmissibility - U.s. Citizenship And Immigration Services Page 6
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12Part 5. Information About Your Qualifying
Other Information
Relatives
5.
What is your relative's relationship to you?
Provide information for your U.S. citizen or lawful permanent
resident through whom you are eligible to submit this
application. In Item Number 9., provide a statement
6.
What is your relative's immigration status?
explaining the extreme hardship that you or your qualifying
relative (U.S. citizen, lawful permanent resident, or other
qualified parent or child) has or will experience if you are
7.
Relative's A-Number (if any)
refused the immigration benefit you are seeking. It is not
►
A-
necessary for an SIJ to complete Part 5. of the application.
8.
Date of Birth (mm/dd/yyyy)
Select here if you are a VAWA self-petitioner and would
like to claim extreme hardship to yourself. (If you are only
Select this box if you have additional relatives through
claiming extreme hardship for yourself, you can skip to Item
whom you claim eligibility and use the space provided in
Number 9. If you have additional qualifying relatives to
Part 10. Additional Information to provide the same
whom you would like to claim extreme hardship, provide
information as requested in Part 5., Item Numbers 1.a. - 8.
their information below.)
Statement From Applicant (Extreme Hardship)
Relative's Full Name
In the space provided below, explain the extreme hardship that
1.a. Family Name
your qualifying relative (or yourself if you are a VAWA self-
(Last Name)
petitioner) would experience if you are refused the immigration
1.b. Given Name
benefit you are seeking. For more information on extreme
(First Name)
hardship, see Form I-601 Instructions. If you need extra space
1.c. Middle Name
to complete your statement, use the space provided in Part 10.
Additional Information or attach a separate letter. Indicate in
Item Number 9. if you are attaching a separate letter. The
Physical Address
letter must be submitted at the same time as your Form I-601
2.a.
Street Number
application.
and Name
9.
2.b.
Apt.
Ste.
Flr.
2.c. City or Town
2.d. State
2.e. ZIP Code
2.f.
Province
2.g. Postal Code
Part 6. Information About Your Other Relatives
With Ties to the United States
2.h. Country
Provide information for any other U.S. citizen, lawful permanent
resident, or any other family members you would like considered
in deciding your case. In the space provided in Item Number 9.,
Contact Information
include a statement explaining why you believe your application
3.
Daytime Telephone Number (if any)
should be approved as a matter of discretion, with the favorable
factors outweighing the unfavorable factors in your case.
4.
Email Address (if any)
Relative's Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
Form I-601 08/21/17 N
Page 6 of 12
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