I-601 Application for Waiver of Grounds of Inadmissibility Personal Statement Template
[Your Full Name]
[A-Number (if any)]
[Your Street Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]
U.S. Citizenship and Immigration Services
[USCIS Office or Service Center Address]
Re: Form I-601, Application for Waiver of Grounds of Inadmissibility
Applicant: [Your Full Name], DOB: [MM/DD/YYYY], A-Number: [A-Number, if any]
1. Introduction and Case Information
I, [Your Full Name], respectfully submit this personal statement in support of my Form I-601, Application for Waiver of Grounds of Inadmissibility.
Full Name: [Your Full Name]
Date of Birth: [MM/DD/YYYY]
Place of Birth: [City, Country]
Citizenship/Nationality: [Country]
Type of Case: [Immigrant Visa / Adjustment of Status / Other]
Underlying Petition or Application: [Type and Receipt Number, e.g., “Form I-130 filed by my U.S. citizen spouse, Receipt Number [Number]”]
Ground(s) of Inadmissibility:
[Description of the section(s) of law and basic reason(s), e.g., unlawful presence, misrepresentation, certain criminal grounds]
2. Personal and Immigration Background
Personal Information:
Full Name: [Your Full Name]
Other Names Used: [Other Names or “None”]
Date of Birth: [MM/DD/YYYY]
Country of Birth: [Country]
Country of Citizenship: [Country]
Immigration History Summary:
Date of First Entry to the United States: [Date or “N/A”]
Manner of First Entry: [With Visa / Visa Waiver / Without Inspection / Other]
Dates of Departures from the United States: [Dates or “None”]
Dates of Reentries to the United States: [Dates or “None”]
Prior Immigration Applications or Petitions: [Form Type – Receipt Number – Date or “None”]
Removal, Voluntary Departure, or Proceedings: [Details or “None”]
3. Explanation of the Ground(s) of Inadmissibility
I understand that I am inadmissible, or may be found inadmissible, under the following section(s) of the Immigration and Nationality Act (INA):
Ground(s) Listed by USCIS or Consulate:
Legal Section(s): [e.g., INA §212(a)(9)(B)(i)(II), INA §212(a)(6)(C)(i)]
Description: [Short description, e.g., “unlawful presence,” “misrepresentation,” “certain criminal offense”]
Factual Background Related to Inadmissibility:
[Brief factual explanation of the conduct or situation that led to the ground(s) of inadmissibility, with dates, places, and key facts.]
4. Qualifying Relative(s)
My request for a waiver is based on the extreme hardship that would be suffered by my qualifying relative(s).
Qualifying Relative 1:
Name: [Full Name]
Relationship to Me: [U.S. Citizen or LPR Spouse / Parent / Other]
Date of Birth: [MM/DD/YYYY]
Citizenship/Status: [U.S. Citizen / Lawful Permanent Resident]
Current Address: [Street, City, State, ZIP Code]
Qualifying Relative 2 (if any):
Name: [Full Name]
Relationship to Me: [Relationship]
Date of Birth: [MM/DD/YYYY]
Citizenship/Status: [U.S. Citizen / Lawful Permanent Resident]
Current Address: [Street, City, State, ZIP Code]
Other Family Members Affected (Non-Qualifying Relatives):
[Names, relationships, ages, and current locations of children or other dependents whose situation is closely connected to the qualifying relative(s).]
5. Emotional and Psychological Hardship
Effect on Qualifying Relative(s) if I Am Not Granted a Waiver:
Emotional Relationship: [Description of closeness, support, and daily involvement between you and each qualifying relative.]
Existing Emotional or Mental Health Conditions: [Diagnosis or symptoms, treatment, medications, therapist or counselor, if any.]
Impact of Separation: [Description of likely emotional impact if you must remain outside the United States or are removed.]
Impact of Relocation: [Description of emotional and psychological hardship if the qualifying relative would have to relocate to your home country.]
Current or Anticipated Counseling or Treatment:
Provider Name (if any): [Name]
Type of Treatment: [Therapy / Counseling / Medication Management / Other]
How Your Presence Affects Their Emotional Stability: [Description]
6. Financial and Practical Hardship
Current Financial Situation:
Household Income Sources: [Employment, self-employment, benefits, other income of you and qualifying relative(s).]
Major Monthly Expenses: [Rent or mortgage, utilities, food, transportation, insurance, childcare, education, medical costs.]
Debts or Financial Obligations: [Loans, credit card debt, support obligations, other liabilities.]
Role in Household Finances:
Your Employment or Earning Capacity: [Job Title, Employer, Income or Potential Income.]
Contributions You Make: [Rent, bills, childcare, elder care, transportation, other support.]
Hardship if You Remain Outside the United States:
Loss or Reduction of Income: [Description and approximate amounts.]
Inability to Meet Basic Expenses: [Rent, mortgage, utilities, bills.]
Impact on Children’s Needs: [Food, housing, school, activities, special services.]
Impact on Qualifying Relative’s Work and Stability: [Job loss risk, reduced hours, missed opportunities.]
Hardship if Qualifying Relative Relocates Abroad:
Loss of Employment or Career: [Description of job, seniority, and effect of leaving.]
Loss of Benefits: [Health insurance, retirement benefits, other benefits.]
Reduced Standard of Living: [Cost of living, wages, housing, or other economic conditions in your home country.]
7. Medical, Educational, and Special Needs Hardship
Medical Conditions of Qualifying Relative(s) or Dependents:
Name: [Full Name]
Condition(s): [Diagnosis or description]
Treating Provider(s): [Doctor/Clinic/Hospital]
Medications or Treatment: [List of key medications, therapies, or treatments]
Consequences if Treatment Is Interrupted or Reduced: [Description]
Availability of Care in Your Home Country:
Access to Comparable Medical Care: [Description of availability, cost, distance, language issues.]
Insurance Coverage or Cost Issues: [Description of limitations or lack of coverage.]
Educational Needs:
Children’s Schools and Programs: [School Names, Grade Levels, Special Programs.]
Special Education or Support Services: [Description of services, evaluations, or accommodations.]
Impact of Separation or Relocation on Education: [Changes in language, curriculum, quality, continuity, or access.]
8. Country Conditions and Safety Concerns
Country of Possible Relocation: [Country]
Relevant Country Conditions:
Security or Violence Concerns: [Conditions in the region where you would live.]
Political, Social, or Religious Issues: [Conditions affecting your family or qualifying relatives.]
Economic Conditions: [Unemployment, wages, inflation, basic living conditions.]
Specific Risks to Qualifying Relative(s):
Health Risks: [Environmental, medical, or public health risks.]
Discrimination or Targeting: [Risks based on nationality, ethnicity, religion, gender, orientation, or other characteristics.]
Lack of Support Network: [Family, community, and other support that would be missing.]
9. Positive Factors, Rehabilitation, and Ties to the United States
Positive Equities and Contributions:
Length of Residence in the United States: [Number of Years]
Employment History: [Jobs, employers, work performance or promotions.]
Tax Compliance: [Years of tax filing, payment history.]
Community or Religious Involvement: [Volunteer work, community groups, church/mosque/temple/synagogue involvement.]
Family Responsibilities: [Caregiving for children, elderly, or disabled relatives.]
Rehabilitation and Remorse (if Relevant):
Nature of Past Mistake or Violation: [Description]
Steps Taken Toward Rehabilitation: [Counseling, classes, treatment programs, community service, lifestyle changes.]
Current Conduct and Stability: [Law-abiding behavior, stable work, family life.]
Ties to the United States and Limited Ties Elsewhere:
Close Family in the United States: [List of relatives and statuses.]
Ties to Home Country: [Family, property, or support remaining abroad, if any.]
10. Supporting Evidence
A separate packet of supporting documents is being submitted with this statement and Form I-601, including, as applicable:
Civil Documents: [Marriage certificates, birth certificates, immigration documents.]
Medical Records: [Letters, reports, prescriptions, treatment summaries.]
Psychological or Counseling Evaluations: [Reports from licensed professionals.]
Financial Records: [Tax returns, pay stubs, bank statements, bills, receipts.]
Employment and Education Records: [Employment letters, school records, transcripts.]
Country Conditions Reports: [Official or reputable reports, articles, or summaries.]
Letters of Support: [Statements from family, friends, community or religious leaders, employers.]
11. Closing Statement and Declaration
I respectfully request that USCIS approve my Form I-601, Application for Waiver of Grounds of Inadmissibility, in light of the extreme hardship that a denial would cause to my qualifying relative(s), [Name(s)], and the positive factors and contributions described above.
I declare under penalty of perjury under the laws of the United States of America that the information in this statement and in my Form I-601 and supporting documents is true and correct to the best of my knowledge and belief.
Executed on [Day] [Month], [Year], in [City, State].
[Your Full Name]
[Signature, if printed]
[Date]
