I-601A Application for Provisional Unlawful Presence Waiver 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 Service Center Address]
Re: Form I-601A, Application for Provisional Unlawful Presence Waiver
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-601A, Application for Provisional Unlawful Presence Waiver.
Full Name: [Your Full Name]
Date of Birth: [MM/DD/YYYY]
Place of Birth: [City, Country]
Citizenship/Nationality: [Country]
Type of Underlying Case: [Immigrant Visa Based on I-130 / I-140 / Other]
Underlying Petition or Case: [Petition Type and Receipt Number, e.g., “Form I-130 filed by my U.S. citizen spouse, Receipt Number [Number]”]
Ground of Inadmissibility (Unlawful Presence):
[Brief description of the period(s) of unlawful presence and corresponding legal section(s), if known.]
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]
Manner of First Entry: [With Visa / Visa Waiver / Without Inspection / Other]
Authorized Stay End Date (if applicable): [Date or “Unknown”]
Period(s) of Unlawful Presence: [Approximate Dates]
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. Qualifying Relative(s)
My I-601A request is based on the extreme hardship that would be suffered by the following qualifying relative(s):
Qualifying Relative 1:
Name: [Full Name]
Relationship to Me: [U.S. Citizen or LPR Spouse / Parent]
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: [U.S. Citizen or LPR Spouse / Parent]
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 wellbeing is closely tied to the qualifying relative(s).]
4. Extreme Hardship if I Must Remain Outside the United States (Separation Scenario)
If my I-601A waiver is denied and I am required to remain outside the United States after my consular interview, my qualifying relative(s) would face the following hardships:
Emotional and Psychological Hardship:
Emotional relationship and dependence between me and my qualifying relative(s): [Description]
Current or past mental health conditions of qualifying relative(s): [Diagnosis or symptoms, if any]
Effect of long-term separation on their emotional and psychological wellbeing: [Description]
Financial Hardship:
Current household income and main sources: [Description and approximate amounts]
My financial contributions to the household: [Amount and type of support]
Impact of my absence on ability to pay rent, mortgage, utilities, food, transportation, education, and other expenses: [Description]
Debts, loans, or other financial obligations that would become difficult to manage: [Description]
Caregiving and Practical Responsibilities:
Childcare, elder care, or support for relatives that I currently provide: [Description]
Impact of my absence on qualifying relative’s ability to work or study: [Description]
Transportation, language, or other practical support I provide: [Description]
5. Extreme Hardship if Qualifying Relative Relocates Abroad (Relocation Scenario)
If my qualifying relative(s) were to relocate with me to [Country of Relocation] instead of remaining in the United States, they would face the following hardships:
Employment and Economic Hardship:
Current job or career of qualifying relative(s) in the United States: [Job Title, Employer, Length of Employment]
Loss of income, seniority, benefits, or career opportunities if they leave the United States: [Description]
Job prospects and likely income in [Country of Relocation]: [Description]
Educational and Language Hardship:
Children’s schooling and educational programs in the United States: [Description]
Impact of moving to [Country] on children’s education, language of instruction, and future opportunities: [Description]
Language barriers for qualifying relative(s) in [Country]: [Description]
Social and Cultural Hardship:
Loss of support from extended family, community, and religious or social networks in the United States: [Description]
Difficulty adjusting to culture, customs, or laws in [Country]: [Description]
Legal and Status-Related Issues:
Loss of rights, benefits, or protections enjoyed as a U.S. citizen or lawful permanent resident if living abroad: [Description]
6. Medical and Special Needs Factors
Medical Conditions of Qualifying Relative(s) or Dependents:
Name: [Full Name]
Medical condition(s): [Diagnosis or description]
Treating provider(s): [Doctor/Clinic/Hospital]
Medications, therapies, or ongoing treatment: [Description]
Consequences if treatment is interrupted or reduced because of separation or relocation: [Description]
Availability and Quality of Care Abroad:
Availability of similar medical care in [Country of Relocation]: [Description]
Cost of treatment and insurance limitations in [Country of Relocation]: [Description]
Special Needs or Disabilities (if any):
Educational, developmental, or physical disabilities in the family: [Description]
Specialized services received in the United States: [Description]
Impact on qualifying relative(s) if these services are lost or reduced: [Description]
7. Financial and Practical Impact in Detail
Household Income and Expenses:
Combined household income: [Amount and description]
Main monthly expenses: [Housing, utilities, food, transportation, insurance, childcare, loans, other]
Role of the Applicant in Financial Support:
Employment history and earning capacity: [Job Title, Employer, Income]
Non-monetary support (childcare, elder care, household responsibilities): [Description]
Consequences of Separation or Relocation:
Increased financial burden on qualifying relative(s): [Description]
Risk of losing housing, health insurance, or education opportunities: [Description]
Need to reduce work hours or leave employment to manage family responsibilities alone: [Description]
8. Country Conditions and Safety Concerns
Country of Relocation: [Country]
Relevant Country Conditions:
Security, crime, or violence concerns in likely area of residence: [Description]
Economic conditions, unemployment, and cost of living: [Description]
Health care system and public services: [Description]
Specific Risks to Qualifying Relative(s):
Health or safety risks: [Description]
Discrimination or social stigma based on nationality, ethnicity, religion, gender, orientation, or other characteristics: [Description]
Lack of family or community support networks in [Country]: [Description]
9. Positive Factors and Ties to the United States
Positive Equities and Contributions:
Length of residence in the United States: [Number of years]
Employment history and work record: [Jobs, employers, responsibilities]
Tax filing and payment history: [Years and general compliance]
Community, religious, or volunteer involvement: [Description]
Family responsibilities and care for children, elderly, or disabled relatives: [Description]
Limited Ties Abroad:
Family, property, or support remaining in home country: [Description or “Minimal”]
Reasons why relocation would be especially difficult despite any remaining ties: [Description]
10. Supporting Evidence
A packet of supporting documents is submitted with this statement and Form I-601A, which may include:
Civil Documents: [Marriage certificates, birth certificates, immigration documents]
Medical Records: [Letters, reports, prescriptions, treatment summaries]
Psychological or Counseling Records: [Evaluations or letters from licensed professionals]
Financial Records: [Tax returns, pay stubs, bank statements, bills, receipts, budgets]
Employment and Education Records: [Employment letters, school records, transcripts]
Country Conditions Evidence: [Reports, articles, and summaries from reputable sources]
Letters of Support: [Statements from family, friends, employers, community or religious leaders]
11. Closing Statement and Declaration
I respectfully request that USCIS approve my Form I-601A, Application for Provisional Unlawful Presence Waiver, in light of the extreme hardship that a denial would cause to my qualifying relative(s), [Name(s)].
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-601A 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]
