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I-191, Application for Advance Permission to Return to Unrelinquished Domicile (United States)

This form is to apply for permission to return to unrelinquished domicile in the United States. The form provided here is simply a sample of what the actual Form I-191 looks like.

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-191, Application for Advance Permission to Return to Unrelinquished Domicile

Action Block

Fee Stamp


Alien Registration Number _______________________________

Date _______________________________

(1) I hereby apply for permission to return to the United States under the authority contained in Section 212(c) of the Immigration and Nationality Act.

MY NAME IS: (First) _______________________________

(Middle) _______________________________

(Last) _______________________________

Date of Birth (mm/dd/yyyy) _______________________________

Place of Birth (City, Province, Country) _______________________________

I am a citizen/National of (Country) _______________________________

Present Address (Street and number, apt. no., city, state, country) _______________________________

(2) I was lawfully admitted to the United States for permanent residence at:

Port of Entry/DHS Office: _______________________________

Date (mm/dd/yyyy) _______________________________

Name of Vessel or Other Means of Conveyance _______________________________

(3) Since that admission I have departed from and reentered the United States as follows:_______________________________

DEPARTED FROM THE UNITED STATES

Port _______________________________

Date (mm/dd/yyyy) _______________________________

Name of Vessel or Other Means of Conveyance _______________________________

RETURNED TO THE UNITED STATES

Port _______________________________

Date (mm/dd/yyyy) _______________________________

Name of Vessel or Other Means of Conveyance _______________________________

PURPOSE OF TRIP

_______________________________


DEPARTED FROM THE UNITED STATES

Port _______________________________

Date (mm/dd/yyyy) _______________________________

Name of Vessel or Other Means of Conveyance _______________________________

RETURNED TO THE UNITED STATES

Port _______________________________

Date (mm/dd/yyyy) _______________________________

Name of Vessel or Other Means of Conveyance _______________________________

PURPOSE OF TRIP

_______________________________

(4) During the past seven years I have resided at the following places: (List present address first)

(Complete Address - Include Apt. No.) _______________________________

From _______________________________

To Present time

(Complete Address - Include Apt. No.) _______________________________

From _______________________________

To _______________________________

(5) During the past seven years I have been employed as follows: (List present employment first)

From _______________________________

To _______________________________

Employer's Name _______________________________

Address _______________________________

Occupation or Type of Business _______________________________


From _______________________________

To _______________________________

Employer's Name _______________________________

Address _______________________________

Occupation or Type of Business _______________________________


(6) My immediate family (spouse, unmarried minor children and parents) consists of the following persons:

Name _______________________________

Relation _______________________________

Date and Country of Birth _______________________________

Citizen of _______________________________

Present Address _______________________________


Name _______________________________

Relation _______________________________

Date and Country of Birth _______________________________

Citizen of _______________________________

Present Address _______________________________

(7) I _______________________________ depart(ed) temporarily from the United States on or about

_______________________________ (Date - mm/dd/yyyy) and will remain

in _______________________________ (Country)

approximately _______________________________ (Length of Time), for the purpose of

_______________________________; and expect to apply for admission at

_______________________________ (Port)

(8) I believe I may be inadmissible to the United States for the following reasons: _______________________________

I understand that the information herein contained may be used in any criminal or civil proceedings, including removal, hereafter instituted against me.

I certify that the statements above are true and correct to the best of my knowledge and belief.

_______________________________ (Signature of Applicant)


Signature of person preparing form, if other than applicant.

I declare that I prepared this petition at the request of the above person and it is based on all information of which I have knowledge.

Signature _______________________________

Address _______________________________

Date _______________________________


Decision:

____ Application granted upon the following terms and conditions:

_______________________________

Date of Action _______________________________

DD _______________________________

District _______________________________

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