Fill and Sign the My United States Address is Form

(Signature ) (Address ) U.S. Department of Justice Immigration and Naturalization Service FEE STAMP (See Instructions on Reverse) FILE NO. 1. MY NAME IS: (Last ) (First ) (Middle ) 2. MY UNITED STATES ADDRESS IS: (Apt. No. ) (Street Number and Name) (Cit y) (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: DATE OF BIRTH: PORT OF ARRIVAL: 7. MANNER OF ARRIVAL: (Name o f Vessel, Airline, etc. ) DATE: 8. PLACE VISA PREVIOUSLY ISSUED: CLASSIFICATION: VALID TO: 9. PLACE PASSPORT ISSU ED: DATE: VALID TO: 10. THE REASON I AM NOT IN POSSESSION OF 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. (Date ) Application disapproved. Application approved. Waiver granted Under Section 211(b) (INS)DATE OF Under Section 212(d)(4) by authorit y of (INS) DD OROIC (State De partment ) until Admitted as (Nonimmi grant Class) 6. DATE OF ARRIVAL: Application for Waiver of Passport and/or Visa OMB No. 1115-0042 PASSPORT VISA IS AS FOLLOWS: Form I-193 (Rev. 11/25/01)Y APPLICANT NOT TO WRITE BELOW THIS LINE (CONTINUE ON REVERSE, IF YOU NEED ADDITIONAL SPACE). INSTRUCTIONS FEE: A fee of $195.00 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. Payment by check or money order must be drawn on a bank or other institution located in the United States and be payable in United States currency. If applicant resides in Guam, a check or money order must be payable to the "Treasurer, Guam." If applicant resides in the Virgin Islands, a check or money order must be payable to the "Commissioner of Finance of the Virgin Islands." All other applicants must make a check or money order payable to the "Immigration and Naturalization Service." When a check is drawn on an 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 drawn on a financial institution in the United States and payable to the Immigration and Naturalization Service 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 bank on which it is drawn. Authority:The authority for collection of the information requested on this form is contained in 8 USC 1182. Submission of the information is voluntary. The collected information will be used principally by the Service to determine whether the applicant is eligible for entry into the United States under the provisions of section s 211, 212, 214, 235, and 251 of the Immigration and Nationality Act. The information solicited may, as a matter of routine use, be disclosed to other federal, state, local, and foreign law enforcement and regulatory agencies. To elicit further information required by INS to carry out its functions, during the course of investigation, this information may also be disclosed to the Department of Defense including any component thereof (if the applicant has served, or is serving in the Armed Forces of the United States), the Department of State, Central Intelligence Agency, Interpol and individuals and organizations. Failure to provide any or all of the solicited information may result in the denial of the application. Reporting Burden:Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Immigration and Naturalization Service, HQPDI, 425 I Street, N.W., Room 4034, Washington, DC 20536; OMB No. 1115-0042. DO NOT MAIL YOUR COMPLETED APPLICATION TO THIS ADDRESS. Form I-193 (Rev. 11/25/01)Y Page 2