Fillable Application For Waiver Of Ground Of Excl (ILW.COM)

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Application For Waiver Of Ground Of Excl (ILW.COM)

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The Application For Waiver Of Ground Of Excl (ILW.COM) form is 6 pages long and contains:

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  • 18 check-boxes
  • 234 other fields

Country of origin: US
File type: PDF

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Fee Stamp
Do not write in this block. For Government use only.
B. Information about relative, through whom applicant claims
eligibility for a waiver
A. Information about applicant
(Middle)
(First)
1. Family Name (Surname In CAPS)
(First)
(Middle)
2. Address (Number and Street)
(Apartment Number)
2. Address (Number and Street)
3. (Town or City)
(Zip/Postal Code)
3. (Town or City)
4. Date of Birth (mm/dd/yyyy)
5. Immigration Status
4. Relationship to Applicant
5. USCIS File Number
6. City/Province-State of Birth
7a. Country of Birth
8. Date of Visa Application
9. Visa Applied for at:
10. Reason for Inadmissibility: (Please include a statement explaining the acts,
convictions, and medical conditions that make you inadmissible. If you
seek a waiver of inadmissibility because you have a Class A Tuberculosis
condition (as per HHS regulations), you must complete page 3 of this
form. If you seek a waiver because you have a HIV infection, you must
complete page 4 of this form. Applicants with physical or mental disorders
must attach the information requested in the instructions.)
11. Applicant was previously in the United States, as follows:
From (Date)
To (Date)
City and State
12. Applicant's U.S. Social Security Number (if any)
Initial receipt
Immigration Status
Sent
Returned
Received
A-
Denied
1. Family Name (Surname in CAPS)
Completed
Form I-601 (Rev.10/30/08)Y
FOR USCIS USE ONLY. DO
NOT WRITE IN THIS AREA.
Department of Homeland Security
U.S. Citizenship and Immigration Services
Resubmitted
Approved
Relocated
212 (a) (1)
212 (a) (2)
212 (a) (6)
212 (a) (9)
Telephone Number
E-Mail Address
7b. Country of
Citizenship/Nationality
E-Mail Address
Telephone Number
OMB No. 1615-0029; Expires 02/28/09
I-601, Application for Waiver
of Grounds of Inadmissibility
(State/Country)
(State)
Copy
TPS Applicant:
212 (a) (3)
(Middle)
(First)
1. Family Name (Surname in CAPS)
(Apartment Number)
2. Address (Number and Street)
(Zip/Postal Code)
3. (Town or City)
5. Immigration Status
4. Relationship to Applicant
C. Information about applicant's other relatives in the United
States (List only U.S. citizens and permanent residents)
Form I-601 (Rev.10/30/08)Y Page 2
Applicant's Signature and Certification.
Signature of Applicant or Qualified Relative / Legal Guardian
Date
Preparer's Address
Date
(Middle)
(First)
1. Family Name (Surname in CAPS)
(Apartment Number)
2. Address (Number and Street)
(Zip/Postal Code)
3. (Town or City)
5. Immigration Status
4. Relationship to Applicant
(Middle)
(First)
1. Family Name (Surname in CAPS)
(Apartment Number)
2. Address (Number and Street)
(Zip/Postal Code)
3. (Town or City)
5. Immigration Status
4. Relationship to Applicant
(State)
(State)
(State)
Copy
I certify under penalty of perjury under the laws of the United States that this
application and the evidence submitted with it are all true and correct to the best
of my knowledge and abilities. I authorize the release of any information from
my records that the U.S. Citizenship and Immigration Services (USCIS) needs
to determine my eligibility for this waiver.
Preparer's Signature and Certification.
I declare that this document was prepared by me at the request of the applicant
or qualified relative/legal guardian of the applicant, and it is based on all
information of which I have knowledge and/or was provided to me by the above
named person in response to the exact questions contained on this form. I have
not knowingly withheld any information.
Preparer's Signature
Date
To Be Completed for Applicants With Class A
Tuberculosis Condition (As Per HHS Regulations).
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 2
or 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:
A. Statement by Applicant
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.
NOTE: If further assistance is needed, contact the USCIS office
with jurisdiction over the intended place of U.S. residence of the
applicant.
Signature of Applicant
(Apt #)
Address (Number and Street)
Date
City, State and Zip Code
(May be executed by a private physician, health department or
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:
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
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.
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)
City, State and Zip Code
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
Date
Signature of Physician
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.)
Form I-601 (Rev.10/30/08)Y Page 3
Upon admission to the United States I will:
B. Statement by Physician or Health Facility
C. Applicant's Sponsor in the United States
(Room/Suite Number)
If you are approved for a waiver and after admission to the United States
you fail to comply with the terms, conditions, and controls that were
imposed, you may be subject to removal under Immigration and
Nationality Act (INA) section 237(a).
1.
2.
3.
4.
1.
2.
A. Statement About Applicant
Upon admission to the United States I will:
1. Go directly to the physician or health facility named in
Section B;
2. Present copies of diagnostic tests used in 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.
Signature of Applicant
Date
B. Statement by Physician or Health Facility
(May be executed by a private physician, health department,
or other public or private facility, or military hospital.)
I agree to supply counseling and any treatment or
observation necessary for the proper management of the
alien's HIV infection condition.
I agree to submit a copy of my evaluation of the alien's
condition to the health officer named in Section D and to the
Division of Quarantine (E03), Centers for Disease Control
and Prevention (CDC), Atlanta Georgia 30333:
1. Within 30 days of the alien's reporting for care, indicating
plans for future care of the alien; or
2. A report that the alien has not reported within 30 days
after receiving a notice from the Division of Quarantine,
CDC.
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 Physician or Facility (Please type or print)
Address (Number & Street)
City, State, & 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 of facility complete Section B.
If medical care will be provided by a physician who
checked box 2 or 3 in Section B, have Section D
completed by the local or State Health Officer who has
jurisdiction in the area where the applicant plans to reside
in the United States.
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 where the alien plans to reside in the United States:
Address (Number & Street) APT No.
City, State, & 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 HIV infection.
If the facility or physician who signed in Section B is not in
your health jurisdiction and is not familiar to you, you may
wish 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 to which the "Notice of Arrival of Alien with
HIV infection Waiver" should be sent when the alien
arrives in the United States.
Official Name of Department
Address (Number & Street) APT No.
City, State, & Zip Code
Please read instructions with care.
Form I-601 (Rev. 10/30/08)Y Page 4
To Be Completed for Applicants With
Human Immunodeficiency Virus (HIV) Infection
NOTE: If further assistance is needed, contact the USCIS
office with jurisdiction over the intended place of U.S.
residence of the applicant.
If you are approved for a waiver and after admission to the
United States you fail to comply with the terms, conditions, and
controls that were imposed, you may be subject to removal
under Immigration and Nationality Act (INA) section 237(a).
Fee Stamp
Do not write in this block. For Government use only.
B. Information about relative, through whom applicant claims
eligibility for a waiver
A. Information about applicant
(Middle)
(First)
1. Family Name (Surname In CAPS)
(First)
(Middle)
2. Address (Number and Street)
(Apartment Number)
2. Address (Number and Street)
3. (Town or City)
(Zip/Postal Code)
3. (Town or City)
4. Date of Birth (mm/dd/yyyy)
5. Immigration Status
4. Relationship to Applicant
5. USCIS File Number
6. City/Province-State of Birth
7a. Country of Birth
8. Date of Visa Application
9. Visa Applied for at:
11. Applicant was previously in the United States, as follows:
From (Date)
To (Date)
City and State
12. Applicant's U.S. Social Security Number (if any)
Initial Receipt
Immigration Status
Sent
Returned
Received
A-
Denied
1. Family Name (Surname in CAPS)
Completed
Form I-601 (Rev. 10/30/08)Y Page 5
FOR USCIS USE ONLY. DO
NOT WRITE IN THIS AREA.
Department of Homeland Security
U.S. Citizenship and Immigration Services
Resubmitted
Approved
Relocated
212 (a) (1)
212 (a) (2)
212 (a) (9)
212 (a) (6)
Telephone Number
E-Mail Address
7b. Country of
Citizenship/Nationality
E-Mail Address
Telephone Number
OMB No. 1615-0029; Expires 02/28/09
I-601, Application for Waiver
of Grounds of Inadmissibility
(State/Country)
(State)
AGENCY COPY
10. Reason for Inadmissibility: (Please include a statement explaining the acts,
convictions, and medical conditions that make you inadmissible. If you
seek a waiver of inadmissibility because you have a Class A Tuberculosis
condition (as per HHS regulations), you must complete page 3 of this
form. If you seek a waiver because you have a HIV infection, you must
complete page 4 of this form. Applicants with physical or mental disorders
must attach the information requested in the instructions.)
TPS Applicant:
212 (a) (3)
Address
Date
Signature and Title of Requesting Officer
USCIS Use Only: Additional Information and Instructions
AGENCY COPY
Form I-601 (Rev.10/30/08)Y Page 6
(Middle)
(First)
1. Family Name (Surname in CAPS)
(Apartment Number)
2. Address (Number and Street)
(Zip/Postal Code)
3. (Town or City)
5. Immigration Status
4. Relationship to Applicant
C. Information about applicant's other relatives in the United
States (List only U.S. citizens and permanent residents)
(Middle)
(First)
1. Family Name (Surname in CAPS)
(Apartment Number)
2. Address (Number and Street)
(Zip/Postal Code)
3. (Town or City)
5. Immigration Status
4. Relationship to Applicant
(Middle)
(First)
1. Family Name (Surname in CAPS)
(Apartment Number)
2. Address (Number and Street)
(Zip/Postal Code)
3. (Town or City)
5. Immigration Status
4. Relationship to Applicant
(State)
(State)
(State)
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Application For Waiver Of Ground Of Excl (ILW.COM)

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Completed 9 January 2021

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