OMB No. 1651-0107 Expires 11/30/2017 FEE STAMP DEPARTMENT OF HOMELAND SECURITY APPLICATION FOR WAIVER OF PASSPORT AND/OR VISA FILE NUMBER 1. MY NAME IS: (LAST) (FIRST) (MIDDLE) 2. MY UNITED STATES DESTINATION IS: (NUMBER AND STREET, APT. NO., CITY, STATE, ZIP CODE) 3. MY PERMANENT ADDRESS ABROAD IS: 4. THE COUNTRY OF WHICH I AM A CITIZEN, SUBJECT OR NATIONAL IS: 5. PLACE OF BIRTH 6. DATE OF ARRIVAL: PORT OF ARRIVAL: DATE OF BIRTH (MM/DD/YYYY): 7. MANNER OF ARRIVAL (NAME OF VESSEL, AIRLINE, ETC.) 8. PLACE VISA PREVIOUSLY ISSUED: 9. PLACE PASSPORT ISSUED: 10. THE REASON I AM NOT IN POSSESSION OF DATE: DATE: PASSPORT NUMBER: NUMBER: VISA CLASSIFICATION: VALID TO: VALID TO: IS AS FOLLOWS: (CONTINUE ON REVERSE, IF NECESSARY) DATE OF THIS APPLICATION: CITY AND STATE: I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT. SIGNATURE OF APPLICANT SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT. I DECLARE THAT THIS DOCUMENT WAS PREPARED BY ME AT THE REQUEST OF THE APPLICANT AND IS BASED ON ALL INFORMATION OF WHICH I HAVE ANY KNOWLEDGE. SIGNATURE ADDRESS DATE APPLICANT - DO NOT WRITE BELOW THIS LINE APPLICATION APPROVED. WAIVER GRANTED UNDER SECTION 211(b) BY AUTHORITY OF UNDER SECTION 212(d)(4) BY AUTHORITY OF (DHS) APPLICATION DISAPPROVED. DATE OF ACTION (DHS) DFO OR PD OFFICE ADMITTED AS NONIMMIGRANT CLASS UNTIL DHS Form I-193 (12/14) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Fee: A fee of $585.00 must be paid for filing this application. It cannot be refunded regardless of the action taken on the application. Do not mail cash. All fees must be submitted in the exact amount. If the application is being made in Guam, a check or money order must be payable to the "Treasurer, Guam." If the application is being made in the U.S. Virgin Islands, a check or money order must be payable to the "Commissioner of Finance of the Virgin Islands." Some filing locations have the capability to accept credit cards. Please inquire with the individual filing location as to their ability to accept credit cards. All other applicants must make a check or money order payable to U.S. Customs and Border Protection or Department of Homeland Security. When a check is drawn on the account of a person other than the applicant, the name of the applicant must be entered on the face of the check. If the application is submitted from outside the United States, remittance may be made by a bank international money order or foreign draft which is payable in United States currency, drawn on a financial institution located in the United States and made payable to U.S. Customs and Border Protection or Department of Homeland Security. All personal checks and money orders must be drawn on a bank or other institution located in the United States and be payable in United States currency. Personal checks are accepted subject to collection. An uncollected check will render the application and any document issued pursuant thereto invalid. A charge of $30.00 will be imposed if a check in payment of a fee is not honored by the financial institution on which it is drawn. Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0107. The estimated average time to complete this application is 10 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 90 K Street, NE., Washington DC 20229. DHS Form I-193 (12/14) American LegalNet, Inc. www.FormsWorkFlow.com
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