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)
APPLICANT NOT TO WRITE BELOW THIS LINE
---------------------------------
____ 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 _______________________________