Application for Provisional Unlawful Presence Waiver

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form I-601A

OMB No. 1615-0123

Expires 07/31/2018

For USCIS Use Only

Initial Receipt

Fee Stamp

Resubmitted

Relocated

Received

Sent

Action Block

To be completed by an attorney or BIA-accredited representative (if any).

Select this box if Form G-28 is attached to represent the applicant.

Attorney State Bar Number (if applicable)

Attorney or Accredited Representative USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Provide the following information about yourself:

1. Alien Registration Number (A-Number) (if any) ►A-

2. U.S. Social Security Number (if any)

3. USCIS Online Account Number (if any)

4.a. Family Name (Last Name)

4.b. Given Name (First Name)

4.c. Middle Name