Form I-192, Addendum Page
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Page 4, Part 2, Question 26 - Immigration and Criminal History
I believe I may be in admissible for the following reasons:
Inadmissibility reasons (Will check only the ones that apply)
[] Yes [] No I am a non-immigrant without a valid passport
[] Yes [] No I am an alien present without being admitted.
[] Yes [] No I have resided in the United States illegally for over one year.
[] Yes [] No I have been arrested in the United States.
[] Yes [] No I have been unlawfully present for more than one year, then left the US and later re-entered or attempted to enter without being admitted.
[] Yes [] No I have been ORDERED removed from the United States
[] Yes [] No I have been PHYSICALLY removed from the United States
[] Yes [] No I have presented false documents at the border.
[] Yes [] No I have claimed to be a US Citizen
[] Yes [] No I have lied to obtain immigration benefits
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Page 4, Part 2, Question 30 - Presence in the U.S. of more than six months
__________ to _________,
Immigration Status at time of entry: ____________
__________ to _________,
Immigration Status at time of entry: ____________
__________ to _________,
Immigration Status at time of entry: ____________
Page 4, Part 2, Question 34 - RE: Arrests and/or Detention
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"Yes, I have been apprehended and/or detained by Customs and Border Patrol or Immigration and Customs Enforcement while attempting to enter the US illegally. I was in custody for ____ days / hours. I was voluntarily returned or deported”.
“Yes, I have been arrested and charged with committing a crime; I am submitting my background check results and associated criminal disposition(s)”.
Number of arrests: _____
Date of Arrest / Detention: ____________
Reason for the arrest/detention: ____________
Outcome: ____________
if any, Days in Jail: _________
if any, Fine: __________
if any, Court ordered Class: _________
Date of Arrest / Detention: ____________
Reason for the arrest/detention: ____________
Outcome: ____________
if any, Days in Jail: _________
if any, Fine: __________
if any, Court ordered Class: _________
Date of Arrest / Detention: ____________
Reason for the arrest/detention: ____________
Outcome: ____________
if any, Days in Jail: _________
if any, Fine: __________
if any, Court ordered Class: _________