Form I-601 - Application For Waiver Of Grounds Of Inadmissibility - U.s. Citizenship And Immigration Services Page 7

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Part 6. Information About Your Other Relatives
Statement From Applicant (Discretion)
With Ties to the United States (continued)
In the space provided below, explain why you believe your
application should be approved as a matter of discretion, with
Physical Address
the favorable outweighing the unfavorable factors in your case.
2.a.
Street Number
For more information on discretion, see Form I-601 Instructions.
and Name
If you need extra space to complete your statement, use the
space provided in Part 10. Additional Information or attach a
2.b.
Apt.
Ste.
Flr.
separate letter. Indicate in Item Number 9. if you are attaching
a separate letter. The letter must be submitted at the same time
2.c. City or Town
as your Form I-601 application.
2.d. State
2.e. ZIP Code
9.
2.f.
Province
2.g. Postal Code
2.h. Country
Contact Information
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
3.
Daytime Telephone Number (if any)
Signature
Read the Penalties section of the Form I-601 Instructions
4.
Email Address (if any)
before completing this part. You must file Form I-601 while in
the United States.
Other Information
Applicant's Statement
5.
What is your relative's relationship to you?
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
6.
What is your relative's immigration status?
and understand every question and instruction on this
application and my answer to every question.
1.b.
The interpreter named in Part 8. read to me every
7.
Relative's A-Number (if any)
question and instruction on this application and my
►
A-
answer to every question, in
8.
Date of Birth (mm/dd/yyyy)
,
a language in which I am fluent, and I understood
Select this box if you have any other relatives with ties to
everything.
the United States and use the space provided in Part 10.
2.
Additional Information to provide the same information
At my request, the preparer named in Part 9.,
as requested in Part 6., Item Numbers 1.a. - 8.
,
prepared this application for me based only upon
information I provided or authorized.
Form I-601 08/21/17 N
Page 7 of 12

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