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: _________