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I-193, Application for Waiver of Passport and/or Visa (United States)

This form is to waive passport or Visa in the United States. The form provided here is simply a sample of what the actual Form I-193 looks like.

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

I-193, Application for Waiver of Passport and/or Visa

Action Block

Fee Stamp

File No. _______________________________

1. My Name Is: (Last) _______________________________

(First) _______________________________

(Middle) _______________________________

2. My United States Address is: (Apt. No.) _______________________________

(Number and Street) _______________________________

(City) _______________________________

(State) _______________________________

(Zip Code) _______________________________

4. The Country of Which I Am A Citizen, Subject or National is: _______________________________

5. Place of Birth _______________________________

Date of Birth (mm/dd/yyyy) _______________________________

6. Date of Arrival _______________________________

Port of Arrival _______________________________

7. Manner of Arrival (Name of Vessel, Airline, etc.) _______________________________

8. Place Visa Previously Issued: _______________________________

Date _______________________________

Classification _______________________________

Valid To: _______________________________

9. Place Passport Issued: _______________________________

Date _______________________________

Valid To: _______________________________

10. The Reason I Am Not In Possession Of (Continue on Separate Sheet(s) of Paper, If Necessary)

____ Passport

____ Visa is as follows: _______________________________

Date of This Application _______________________________

City and State _______________________________

I Certify That the Above is True and Correct

______________________________ (Signature of Applicant)

Signature of person preparing form, if other than applicant.

I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.

_______________________________ (Signature)

_______________________________ (Address)

_______________________________ (Date)



____ Application approved. Waiver granted

____ Under Section 211(b) by authority of _______________________________ (DHS)

____ Under Section 212(d)(4) by authority of with concurrence of _______________________________ (State Department)

Admitted as _______________________________ (Nonimmigrant Class) until ____________________

____ Application disapproved.


Date of Action _______________________________

DD or OIC Office _______________________________

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