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 _______________________________