I-601A Application for Provisional Unlawful Presence Waiver Personal Statement Template

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]