I-601 Application for Waiver of Grounds of Inadmissibility Personal Statement Template

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]