I-601, Application for Waiver of Grounds of Inadmissibility (United States)
This form is for an applicant who was declared inadmissible in the United States. The form provided here is simply a sample of what the actual Form I-601 looks like.
U.S. Department of Homeland Security
Bureau of Citizenship and Immigration Service
I-601, Application for Waiver of Grounds of Inadmissibility
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Do not write in this block. For Government use only.
____ 212 (a) (1)
____ 212 (a) (3)
____ 212 (a) (6)
____ 212 (a) (9)
____ 212 (a) (10)
____ 212 (a) (12)
____ 212 (a) (19)
____ 212 (a) (23)
Fee Stamp
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A. Information about applicant.
1. Family Name (Surname in CAPS) _______________________________
(First) _______________________________
(Middle) _______________________________
2. Address (Number and Street) _______________________________
(Apartment Number) _______________________________
3. (Town or City) _______________________________
(State/Country) _______________________________
(Zip/Postal Code) _______________________________
Telephone Number _______________________________
E-Mail Address _______________________________
4. Date of Birth (mm/dd/yyyy) _______________________________
5. USCIS File Number A- _______________________________
6. City/Province-State of Birth _______________________________
7a. County of Birth _______________________________
7b. Country of Citizenship/Nationality _______________________________
8. Date of Visa Application _______________________________
9. Visa Applied for at: _______________________________
10. Applicant was declared inadmissible to the United States for the following reasons: (List acts, convictions, or physical or mental conditions. If applicant has active or suspected tuberculosis, Page 2 of this form must be fully completed.)
_______________________________
11. Applicant was previously in the United States, as follows:
City and State _______________________________
From (Date) _______________________________
To (Date) _______________________________
Immigration Status _______________________________
City and State _______________________________
From (Date) _______________________________
To (Date) _______________________________
Immigration Status _______________________________
City and State _______________________________
From (Date) _______________________________
To (Date) _______________________________
Immigration Status _______________________________
12. Applicant's U.S. Social Security Number (if any) _______________________________
B. Information about relative, through whom applicant claims eligibility for a waiver.
1. Family Name (Surname in CAPS) _______________________________
(First) _______________________________
(Middle) _______________________________
2. Address (Number and Street) _______________________________
(Apartment Number) _______________________________
3. (Town or City) _______________________________
(State/Country) _______________________________
(Zip/Postal Code) _______________________________
Telephone Number _______________________________
E-Mail Address _______________________________
4. Relationship to Applicant _______________________________
5. Immigration Status _______________________________
1. Family Name (Surname in CAPS) _______________________________
(First) _______________________________
(Middle) _______________________________
2. Address (Number and Street) _______________________________
(Apartment Number) _______________________________
3. (Town or City) _______________________________
(State/Country) _______________________________
(Zip/Postal Code) _______________________________
Telephone Number _______________________________
E-Mail Address _______________________________
4. Relationship to Applicant _______________________________
5. Immigration Status _______________________________
Certification: Signature (of applicant or petitioning relative)
_______________________________
Relationship to Applicant _______________________________
Date _______________________________
PREPARER OF APPLICATION: Signature (of person preparing application, if not the applicant or petitioning relative). I declare that this document was prepared by me at the request of the applicant or petitioning relative, and is based on all information of which I have any knowledge.
Signature _______________________________
Address _______________________________
Date _______________________________
To Be Completed for Applicants With Active Tuberculosis or Suspected Tuberculosis
A. Statement by Applicant.
Upon admission to the United States I will:
• Go directly to the physician or health facility named in Section B;
• Present all X-rays used in the visa medical examination to substantiate diagnosis;
• Submit to such examinations, treatment, isolation and medical regimen as may be required; and
• Remain under the prescribed treatment or observation whether on inpatient or outpatient basis, until discharged.
Signature of Applicant _______________________________
Date _______________________________
B. Statement by Physician or Health Facility.
(May be executed by a private physician, health department, other public or private health facility or military hospital.) I agree to supply any treatment or observation necessary for the proper management of the alien's tuberculosis condition.
I agree to submit Form CDC 75.18, "Report on Alien with Tuberculosis Waiver," to the health officer named in Section D:
• Within 30 days of the alien's reporting for care, indicating presumptive diagnosis, test results and plans for future care of the alien; or
• 30 days after receiving Form CDC 75.18, if the alien has not reported.
Satisfactory financial arrangements have been made. (This statement does not relieve the alien from submitting evidence, as required by consul, to establish that the alien is not likely to become a public charge.)
I represent (enter an "X" in the appropriate box and give the complete name and address of the facility below.)
____ 1. Local Health Department
____ 2. Other Public or Private Facility
____ 3. Private Practice
____ 4. Military Hospital
Name of Facility (Please type or print in black ink) _______________________________
Address (Number and Street) _______________________________
(Room/Suite Number) _______________________________
City, State and Zip Code _______________________________
Signature of Physician _______________________________
Date _______________________________
C. Applicant's Sponsor in the United States.
Arrange for medical care of the applicant and have the physician complete Section B.
If medical care will be provided by a physician who checked Box 2or 3, in Section B, have Section D completed by the local or State Health Officer who has jurisdiction in the United States area where the applicant plans to reside.
If medical care will be provided by a physician who checked Box 4, in Section B, forward this form directly to the military facility at the address provided in Section B.
Address in the United States where the alien plans to reside:
Address (Number and Street) _______________________________
(Apartment Number) _______________________________
City, State and Zip Code _______________________________
D. Endorsement of Local or State Health Officer.
Endorsement signifies recognition of the physician or facility for the purpose of providing care for tuberculosis. If the facility or physician who signed his or her name in Section B is not in your health jurisdiction and not familiar to you, you may want to contact the health officer responsible for the jurisdiction of the facility or physician prior to endorsing.
Endorsed by: Signature of Health Officer _______________________________
Date _______________________________
Enter below the name and address of the Local Health Department where the "Notice of Arrival of Alien with Tuberculosis Waiver" should be sent when the alien arrives in the United States.
Official Name of Department _______________________________
Address (Number and Street) _______________________________
(Room/Suite Number) _______________________________
City, State and Zip Code _______________________________
NOTE: If further assistance is needed, contact the USCIS office with jurisdiction over the intended place of United States residence of the applicant.
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INSTRUCTIONS FOR FILLING OUT THIS FORM
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1. Filing the Application.
The application and supporting documents should be taken or mailed to:
The American Embassy or Consulate where the applicant is applying for a visa, if the applicant is not in the United States; or
The office of the U.S. Citizenship and Immigration Services (USCIS) having jurisdiction over the applicant's place of residence, if the applicant is in the United States and applying for status as a permanent resident.
2. What is the Fee?
• No fee is required if this application is filed for an alien who:
• Is afflicted with tuberculosis;
• Has a history of mental illness.
All other applications must be accompanied by a fee of $265.00.The fee cannot be refunded, regardless of the action taken on the application. Do not mail cash.
NOTE: Only a single application and fee is required when an alien is applying simultaneously for a waiver both sections 212(h) and (i) of the Immigration and Nationality Act.
Payment must be made by a check or money order:
• Drawn on a bank or other institution located in the United States;
• Payable in U.S. currency; and
• Payable in the exact amount.
If the check is drawn on an account of a person other than the applicant, the name of the applicant must be entered on the face of the check.
Personal checks are accepted subject to collectability. An uncollectible check will void the application and any documents issued pursuant to the application. A charge of $30.00 will be imposed if the check is not honored by the bank on which it is drawn.
Unless the applicant resides in the U.S. Virgin Islands or Guam, the check or money order must be made payable to the Department of Homeland Security.
If the applicant resides in Guam, make the check or money order payable to the "Treasurer, Guam."
If the applicant resides in the U.S. Virgin Islands, make the check or money order payable to the "Commissioner of Finance of the Virgin Islands."
How to Check If the Fee Is Correct.
The fee on this form is current as of the edition date appearing in the lower right corner of this page. However, because USCIS fees change periodically, you can verify if the fee is correct by following one of the steps below:
• Visit our website at www.uscis.gov and scroll down to "Forms and E-Filing" to check the appropriate fee, or
• Review the Fee Schedule included in your form package, if you called us to request the form, or
• Telephone our National Customer Service Center at 1-800-375-5283 and ask for the fee information.
3. Applicants With Tuberculosis.
An applicant with active tuberculosis or suspected tuberculosis must complete Statement A on Page 2 of this form. The applicant and his or her sponsor is also responsible for having:
• Statement B completed by the physician or health facility which has agreed to provide treatment or observation, and Statement D, if required, completed by the appropriate local or state health officer.
This form should then be returned to the applicant for presentation to the consular office or appropriate USCIS office.
Submission of the application without the required fully executed statements will result in the return of the application to the applicant without further action.
4. Applicants With Mental Conditions.
An alien who is mentally retarded or who has a history of mental illness shall attach a statement that arrangements have been made for the submission of a medical report, as follows, to the office where this form is filed:
The medical report shall contain:
A complete medical history of the alien, including details of any hospitalization or institutional care or treatment for any physical or mental condition;
Findings as to the current physical condition of the alien, including reports of chest X-rays and a serologic test if the alien is 15 years of age or older, and other pertinent diagnostic tests; and
Findings as to the current mental condition of the alien, with information as to prognosis and life expectancy and with a report of a psychiatric examination conducted by a psychiatrist who shall, in the case of mental retardation, also provide an evaluation of intelligence.
For an alien with a past history of mental illness, the medical report shall also contain available information on which the U.S. Public Health Service can base a finding as to whether the alien has been free of such mental illness for a period of time, sufficient in the light of such history, to demonstrate recovery.
The medical report will be referred to the U.S. Public Health Service for review and, if found acceptable, the alien will be required to submit such additional assurances as the U.S. Public Health Service may deem necessary in his or her particular case.
5. USCIS Forms and Information.
To order USCIS forms, telephone our toll-free forms line at 1-800-870-3676. You can also get USCIS forms and information on immigration laws, regulations and procedures, by calling our National Customer Service Center at 1-800-375-5283 or visiting our website at www.uscis.gov.
6. Use InfoPass to Make an Appointment.
As an alternative to waiting in line for assistance at your local USCIS office, you can now schedule an appointment through our internet-based system, InfoPass. To access the system, visit our website at www.uscis.gov. Use the InfoPass appointment scheduler and follow the screen prompts to set up your appointment. InfoPass generates an electronic appointment notice that appears on the screen. Print the notice and take it with you to your appointment. The notice gives the time and date of your appointment, along with the address of the USCIS office.
7. Public Reporting Burden.
A person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., Washington, D. C. 20529; OMB No. 1615-0029. Do not mail your completed application to this address.