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I-690, Application for Waiver of Grounds of Inadmissibility (United States)

This form is for an applicant who is inadmissible for legal residency under Sections 245A and 210 in the United States. The form provided here is simply a sample of what the actual Form I-690 looks like.


U.S. Department of Homeland Security
Bureau of Citizenship and Immigration Service

I-690, Application for Waiver of Grounds of Inadmissibility

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For Government use only.

Fee Receipt Number (This application): _______________________________

Alien Registration Number (A# of This Applicant): _______________________________


Fee Stamp


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APPLICANT:
See instructions before filling in this application. If you need more space to answer fully any question on this form,
use a separate sheet and identify each answer with the number of the corresponding question. Type or print in black ink.

1. Family Name (Last Name in CAPITAL letters) _______________________________

(First) _______________________________

(Middle) _______________________________

2. Date of Birth (mm/dd/yyyy) _______________________________

2. Address (Number and Street) _______________________________

(Apartment Number) _______________________________

(City/Town) _______________________________

(State/Country) _______________________________

(Zip/Postal Code) _______________________________

4. Place of Birth (City or Town and Country, Province or State) _______________________________

Country _______________________________

5. U.S. Social Security Number _______________________________

6. Date of Visa Application (mm/dd/yyyy) _______________________________

for: ____ Permanent Residence

____ Temporary Residence

7. Visa applied for at: _______________________________

8. I am applying for a waiver of:

____ 212 (a) (1)(A)(i), (ii), (iii) or (iv)
____ 212 (a)(2)(C)(i)(II) - possession of marijuana, 30 gms or less
____ 212 (a)(6)(A)(i)
____ 212(a)(6)(C)(i) or (ii)
____ 212(a)(6)(D) and/or (E)
____ 212(a)(8)(A) and/or (B)
____ 212(a)(9)(A)(i) or (ii)
____ 212(a)(9)(B)(i)(I) or (i)(II)
____ 212(a)(9)(C)(i)(I) or (i)(II)
____ 212 (a)(10)(A), (B), (C), (D), and/or (E) - Please specify: _______________________________

9. List reasons of inadmissibility:_______________________________

10. List all immediate relatives in the United States (parents, spouse and children):

Name _______________________________

Address _______________________________

Relationship _______________________________

Immigration Status _______________________________


Name _______________________________

Address _______________________________

Relationship _______________________________

Immigration Status _______________________________


Name _______________________________

Address _______________________________

Relationship _______________________________

Immigration Status _______________________________


Name _______________________________

Address _______________________________

Relationship _______________________________

Immigration Status _______________________________

11. I should be granted a waiver because:
(Describe family unity considerations or humanitarian or public interest reasons for granting a waiver). If more space is needed attach an additional sheet. _______________________________

12. Applicant's Signature _______________________________

13. Date _______________________________


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FOR USCIS USE ONLY. Recommended by:

(Print Name and Title) _______________________________

Date _______________________________

Signature _______________________________

Stamp # _______________________________

Director _______________________________

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Supplement for Applicants With Human Immunodeficiency Virus (HIV) Infection or Tubercoulosis (TB)

Part A. Applicant's Sponsor in the U.S.

1. Make arrangements for the applicant's medical care and have the attending physician or facility complete Part C.

2. Obtain the necessary endorsements.

a. Treatment is being provided by a state or local health department: If a state or local health department will provide the necessary care and/or treatment to the applicant, that facility should check block (a) in Number 4 under Part C . The health department is not required to complete anything else on this form.

b. Treatment is being provided by a private physician or by any other private or public facility: If a private physician, a private medical facility or a public medical facility (other than a state or local health department) will provide the applicant's medical care and/or treatment, that facility should check block (b) or (c) under Number 4 of Part C, as applicable. In that case, the state or local health department in the jurisdiction where the applicant will reside must complete Part D.

3. Address in the United States where the applicant plans to reside:

Address (Number and Street) _______________________________

(Apartment No.) _______________________________

City, State and Zip Code _______________________________

Part B. Applicant's Statement:

Upon admission to the United States I will:

1. Go directly to the physician or health facility named in Number 5 of Part C;

2. Present copies of diagnostic tests used on the visa examination to substantiate diagnosis;

3. Submit to counseling and such examinations, treatment and medical regimen as may be required; and

4. Remain under prescribed treatment or observation whether on inpatient or outpatient basis, until discharged.

Part C. Statement by Physician or Health Facility:

1. I agree to supply counseling and any treatment or observation necessary for the proper management of the applicant's condition. (Check applicable box(es):

____ HIV Infection ____ Tuberculosis

2. I agree to submit a copy of my evaluation to the Division of Global Migration and Quarantine (E03), Centers for Disease Control and Prevention, Atlanta, Georgia 30333, and certify the following:

a. I will submit a copy of my evaluation within 30 days of the date the applicant is required to appear for evaluation and/or care; and

b. If at the end of the 30-day period the applicant fails to appear for evaluation and/or care as required, I will submit a report to that effect to the CDC.

3. Satisfactory financial arrangements have been made for the applicant's medical care and treatment. (This statement does not relieve the applicant from submitting evidence, as required by the consular officer or USCIS, to establish that he or she is not likely to become a public charge (another ground of inadmissibility under section 212(a)(4) of the Immigration and Nationality Act).

4. I represent: (Check the appropriate box and provide the information requested below)

____ Local Health Department
____ Other Public or Private Facility
____ Private Medical Practice

I agree to submit a copy of my evaluation to the health officer indicated in Part D. (Required if you checked block (b) or (c) in Number 4 directly above.)

Name of Physician or Facility (Please type or print) _______________________________

Address (Number and Street) _______________________________

City, State and Zip Code _______________________________

Signature of Physician _______________________________

Date _______________________________

Part D. Endorsement of Local or State Health Officer:

Endorsement signifies recognition of the physician or facility for the purpose of providing care for HIV infection or tuberculosis. If the facility physician who signed in Part C is not in your health jurisdiction or is not familiar to you, you may wish to contact the health officer responsible for the jurisdiction, and/or the physician, before you sign this endorsement.

Official Name of Department (Please type or print) _______________________________

Signature _______________________________

Date _______________________________

Name of Health Department to receive the required notice from the CDC following the Applicant's arrival in the U.S./adjustment of status. (Please type or print)

Address (Number and Street) _______________________________

City, State and Zip Code _______________________________


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INSTRUCTIONS FOR FILLING OUT THIS FORM
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1. What Is the Purpose of This Form?

This form is used to apply for a waiver of inadmissibility by an applicant for adjustment of status under section 245A or 210 of the Immigration and Nationality Act (INA).

A separate waiver application must be filed by each applicant who is inadmissible. All applications must be typed or clearly printed in black ink and completed in full. If extra space is needed to answer an item, attach a continuation sheet and indicate your name, "A" file number and item number.

2. Special Instructions for Individuals Applying for a Waiver of One or More of the Medical Grounds Under Section 212(a)(1)(A) of the INA.

Applicants who Require a Waiver for Human Immunodeficiency Virus (HIV) or Tuberculosis (TB).

The physician or medical facility that will provide the required treatment to you must fill out Part C of the accompanying TB/HIVsupplement. If that physician or health care facility is not part of the state or local health department, then the local health department in the jurisdiction where you will reside must also complete and sign Part D . If you are outside of the United States, a relative in the United States must complete this process for you.

After the TB/HIV supplement has been completed, attach the supporting documents and file your waiver application. If you are inadmissible because of HIV and/or TB and your waiver application does not include a properly completed HIV/TB supplement, your waiver application will be returned to you.

B. Applicants Requesting a Waiver of the Vaccination Requirements of INA 212(a)(1)(A)(ii)

If your waiver application is based on religious or moral objections to vaccinations, you must establish that:

• You object to vaccinations in any form; and

• You object because of your religious beliefs or moral convictions (you do not need to be a member of a "mainstream" or recognized religion); and

• Your beliefs are sincere.

At a minimum, you must submit a personal statement describing the basis of your objection.

You can apply for a waiver of the vaccination requirements without filing this form and without paying a fee, if:

• You initially did not submit proof that you have received the required vaccines, but you are vaccinated now; or

• It is not medically appropriate for you to have one or more of the missing vaccines. The physician will make this certification according to the applicable regulations published by the Department of Health and Human Services (HHS) and the accompanying technical instructions for physicians designated to perform the required medical examination. These instructions are published by the Centers for Disease Control and Prevention (CDC). According to these technical instructions, "not medically appropriate" covers the following situations:

- The vaccination is not recommended by the Advisory Committee for Immunization Practices (ACIP) for your age group; or

- The vaccination is medically contraindicated; or

- There is an insufficient interval between doses for vaccines requiring a series of doses; or

- It is not the flu season (for the flu vaccine only).

C. Applicants Who Have a Physical or Mental Disorder With Associated Harmful Behavior - INA 212(a)(1)(A) (iii)(I) or (II).

If the examining physician determines that you have a physical or mental disorder with associated harmful behavior, or a past history of a physical or mental disorder with harmful behavior that is likely to recur, the medical examination report completed by the designated physician will, at a minimum, contain the following information, as required by HHS regulations at 42 CFR part 34 and the accompanying technical instructions published by the CDC:

• A complete medical history, including the details of any prior or current hospitalization, treatment, or care;

• The current findings, diagnosis, and prognosis; and

• Any other information necessary for USCIS to determine, in consultation with HHS, the terms and conditions that should be imposed on the waiver, if it is granted.

Applicants Who Are Inadmissible because of Substance or Drug Abuse or Substance or Drug Addiction - INA 212(a)(1)(A)(iv)

The designated physician will determine whether you are currently using, or have used in the past, any controlled or psychoactive substance. The examining physician will make this determination during the required medical exam, according to the applicable HHS regulations at 42 CFR part 34 and the accompanying technical instructions published by the CDC.

If you are inadmissible under INA 212(a)(1)(A)(iv) due to drug abuse or drug addiction, you may apply for a waiver.

USCIS will exercise discretion in determining whether to grant this waiver, after consulting with HHS, and if you are not inadmissible on any other grounds that cannot be waived.

You are not inadmissible under INA 212(a)(1)(A)(iv) if the designated physician that performed the required medical exam determined that you are in remission for prior drug use or abuse or that your prior drug use was strictly experimental. The designated physician will determine whether any prior drug use is in remission, or whether it was strictly experimental, based on the applicable HHS regulations and the accompanying technical instructions published by the CDC.

Note the following key items:

If you engaged in the use of any controlled substance, and such use was illegal at the place where it occurred, your admission to the examining physician may be sufficient to make you inadmissible on criminal grounds under INA 212(a) (2)(A)(i)(II) relating to any controlled substance violation (U.S. or foreign).

The USCIS officer reviewing your primary benefit application (Form I-687, Form I-698, Form I-700, and/or Form I-485) will determine whether this admission to the designated physician makes you inadmissible under INA 212(a)(2)(A)(i)(II).

The only drug offense under INA 212(a)(2)(A)(i)(II) that can be waived is one offense of simple possession of marijuana (30 grams or less).

Any willful concealment or misrepresentation of any material fact made to procure an immigration benefit (including any willful concealments or misrepresentations made to avoid being found inadmissible under any provision), will result in the denial of this waiver application and your primary benefit application. You may also become subject to additional penalties under the law.

3. What is the Fee?

You must pay $95.00 to file this application. The fee is not refundable, whether the application is approved or denied.

Do not mail cash . A separate check or money order must be submitted for each application. All checks or money orders, whether U.S. or foreign, must be payable in U.S. currency at a financial institution in the United States. When a check is drawn on the account of a person other than yourself, write your name on the face of the check. If the check is not honored, USCIS will charge you $30.00.The check or money order must be in the exact amount payable to the U.S. Department of Homeland Security, unless:

If you live in Guam, make the check or money order payable to the "Treasurer, Guam" or

If you live in the U.S. Virgin Islands, make your 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.

4. Where Must the Application Be Filed?

You must file this waiver application with the USCIS office that has jurisdiction over your primary benefit application -- Form I-687, Form I-698 and/or Form I-485.

5. Do You Need USCIS Forms or Information.

To order USCIS forms, call our toll-free forms line at 1-800-870-3676. You can also obtain information on immigration laws, regulations or procedures by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our internet 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.

Paperwork Reduction Act Notice.

An agency may not conduct or sponsor an information collection and a person is not required to respond to this collection of information unless it displays a currently valid OMB control number.

The estimated average time to complete and file this application is 15 minutes per application.

If you have comments regarding this form you can write to U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., Washington, DC 20529; OMB No. 1615-0032. Do not mail your completed application to this address.

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