Form G 646 Sworn Statement – Fill Out and Use This PDF

OMB No. 1615-0097; Expires 05/31/2011

Penalties

If you knowingly or willfully misrepresent or omit a material fact or submit a false document with this form, we may deny your immigration benefit. In addition, you may face severe penalties provided by law, including criminal prosecution.

Privacy Act Notice

We ask for the information on this form, and associated evidence, to determine if you are eligible for the immigration benefit you seek. Failure to provide requested information and/or evidence may delay a final decision or result in denial of your immigration benefit. We may provide this information to other government agencies.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 20 minutes per response, including the time for reviewing instructions, and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Products Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210, OMB No. 1615-0097. Do not mail Form G-646 to this address.

All applicants for refugee status must establish that they are admissible. Use blue or black ink. Check the appropriate box in response to each question asked below. If your answer to a question is "Yes," provide an explanation on a separate sheet of paper. Answering "Yes" will not necessarily exclude you from admission to the United States.

YesNo

1. Have you EVER been detained, arrested, or otherwise placed under the custody or control of a law enforcement entity for any reason and for any length of time?

2. Have you EVER been cited, charged, indicted, convicted, fined, imprisoned, or otherwise penalized for breaking or violating any law or ordinance, excluding traffic violations?

3. Have you EVER knowingly committed, or helped someone else commit, any crime(s), excluding traffic violations, for which you have not been arrested?

4.Have you EVER:

a. Been the beneficiary of a pardon, amnesty, rehabilitation decree, or other act of clemency or similar action?

b. Benefited from diplomatic immunity to avoid prosecution for a criminal offense in the United States or any other country?

c. Illicitly trafficked (illegally transported, traded, dealt, or sold) in any illegal narcotic or other controlled substance, or knowingly assisted, abetted, or conspired in the illicit trafficking of any substance?

Form G-646 (Rev. 05/28/10) N

YesNo

d. Engaged in any unlawful commercialized vice, including but not limited to illegal gambling?

e. Knowingly encouraged, induced, assisted, abetted, or aided any alien to try to enter the United States illegally?

f. Within the past 10 years been a prostitute or procured anyone for prostitution?

5. Have you EVER been subject to deportation or removal from the United States?

6. Have you EVER voted illegally in the United States?

7. Have you EVER been a citizen of the United States who has renounced that citizenship to avoid taxation?

8. Have you EVER left the United States to avoid being drafted into the U.S. Armed Forces?

9. Have you EVER been subject to a civil document fraud final order for violating section 274C of the Immigration and Nationality Act of the United States?

10. Are you now withholding custody of a U.S. citizen child outside the United States from a person granted custody of the child?

11. Did you, during the period March 23, 1933, to May 8, 1945, in association with either Nazi Government of Germany or any other organization or government associated or allied with the Nazi Government of Germany, ever order, incite, assist, or otherwise participate in the persecution of any person because of race, religion, national origin, or political opinion?

12. Have you EVER been a member of, or in any way affiliated with, the Communist party or any totalitarian party, or any subdivision or affiliate of such parties?

13.Have you EVER:

a. Engaged in, conspired to engage in, or do you intend to engage in sabotage, kidnapping, political assassination, hijacking, or any other form of terrorist activity?

b. Solicited membership or funds for, or ever voluntarily assisted or provided any type of material support to, any person or organization that has ever engaged in sabotage, kidnapping, political assassination, hijacking, or any other form of terrorist activity?

c. Been a representative or member of a terrorist organization?

d. Endorsed or espoused terrorist activity, or persuaded others to endorse or espouse terrorist activity or support a terrorist organization?

e. Been a member of a political, social, or other group that endorsed or espoused terrorist activity?

14. If married, has your spouse EVER participated in any of the activities listed in Question 13?

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YesNo

15. If between the ages of 14 and 21, has your parent EVER participated in any of the activities listed in Question 13?

16.While in the United States, do you intend to engage in:

a. Espionage?

b. Any activity a purpose of which is opposition to, or the control or overthrow of the Government of the United States by force, violence, or other unlawful means?

c. Any activity to violate or evade any law prohibiting the export from the United States of goods, technology, or sensitive information?

d. Polygamy (simultaneous marriage to more than one spouse)?

e. Prostitution?

17.Have you EVER ordered, incited, called for, committed, assisted, helped with, or otherwise participated in any of the following:

a. Acts involving torture or genocide?

b. Killing any person?

c. Intentionally and severely injuring any person?

d. Engaging in any kind of sexual contact or relations with any person who was being forced or threatened?

e. Limiting or denying any person's ability to exercise religious beliefs?

18.Have you EVER:

a. Served in, been a member of, assisted in, or participated in any military unit, paramilitary unit, police unit, self-defense unit, vigilante unit, rebel group, guerrilla group, militia, or insurgent organization?

b. Served in any prison, jail, prison camp, detention facility, labor camp, or any other situation that involved detaining persons?

19. Have you EVER been a member of, assisted in, or participated in any group, unit, or organization of any kind in which you or other persons used any type of weapon against any person or threatened to do so?

20. Have you EVER assisted or participated in selling or providing weapons to any person who to your knowledge used them against another person, or in transporting weapons to any person who to your knowledge used them against another person?

21. Have you EVER received any type of military, paramilitary, or weapons training?

22. Have you EVER knowingly recruited a child under 15 years of age to serve in an armed force or group or used a child under 15 years of age to participate actively in hostilities?

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YesNo

23. Have you, by fraud or willful misrepresentation of a material fact, EVER sought to procure, or procured, a visa, other documentation, entry into the United States, or any other immigration benefit?

24.Do you:

a. Currently have any communicable disease of public health significance (including chancroid, gonorrhea, granuloma inguinal, human immunodeficiency virus (HIV) infection, infectious leprosy, lymphogranuloma venereum, infectious stage syphilis, and active tuberculosis)?

b. Have a physical or mental disorder, and behavior associated with the disorder, that may pose, or has posed, a threat to the property, safety, or welfare of yourself or others?

25. Are you a narcotics user or addict?

Applicant's Statement and Signature (Check one)

I can read and understand English, and I have read and understand each and every question and instruction on this form, as well as my answer to each question.

Each and every question and instruction on this form, as well as my answer to each question, has been read to me in the language, a language in which I am fluent, by the person named in Interpreter's Statement and

Signature. I understand each and every question and instruction on this form, as well as my answer to each question.

I certify, under penalty of perjury under the laws of the United States of America, that the information provided with this Form G-646 is all true and correct. I certify also that I have not withheld any information that would affect the outcome of this Form G-646.

Applicant's Signature		E-Mail Address (if any)		Date (mm/dd/yyyy)

Interpreter's Statement and Signature

I certify that I am fluent in English and the below-mentioned language.

Language Used (language in which applicant is fluent):

I further certify that I have read each and every question and instruction on this form, as well as the answer to each question, to this applicant in the above-mentioned language, and the applicant has understood each and every instruction and question on the form, as well as the answer to each question.

Interpreter's Signature				Date (mm/dd/yyyy)
Printed Name		E-Mail Address (if any)		Telephone Number (with area/country code)

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Preparer's Statement and Signature

I declare that I prepared this Form G-646 at the request of the above applicant and it is based on all information of which I have knowledge. I have not knowingly withheld any material information that would affect the outcome of this Form G-646.

Attorney or Representative: In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?

Preparer's Printed Name		Preparer's Firm Name (if applicable)

Preparer's Address

Daytime Phone Number (with area code) Fax Number (if any)				E-Mail Address (if any)

OFFICIAL USE ONLY

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