Extreme Hardship Waiver Declaration Template

EXTREME HARDSHIP WAIVER DECLARATION TEMPLATE

PURPOSE

This template is a fact-development and declaration framework for a Form I-601 or Form I-601A matter in which the identified waiver provision requires extreme hardship to a qualifying relative. It is not a Form I-212 declaration template. Form I-212 may be relevant to the same immigration history, but it is a separate request for permission to reapply and should not be treated as if extreme hardship were its universal statutory test.

Before drafting, counsel should identify the exact inadmissibility ground, waiver provision, qualifying relative, filing posture, and current USCIS form instructions. Delete every topic that is not true or relevant to the declarant.

EXTREME HARDSHIP STANDARD

Definition

USCIS states that extreme hardship must exceed the hardship usual or expected from family separation or relocation. The officer considers the totality of the evidence and evaluates the factors individually and cumulatively. A favorable extreme-hardship finding does not by itself guarantee approval because the waiver also requires a favorable exercise of discretion.

Qualifying Relatives (Varies by Waiver Type)

• INA § 212(a)(9)(B)(v), including Form I-601A cases: U.S. citizen or LPR spouse or parent
• INA § 212(h)(1)(B): U.S. citizen or LPR spouse, parent, son, or daughter; counsel must confirm that this hardship route applies to the charged ground and applicant
• INA § 212(i)(1): generally a U.S. citizen or LPR spouse or parent; special VAWA rules require separate analysis

Children or other family members who are not qualifying relatives may still matter when their hardship produces hardship to a qualifying relative, but their hardship does not automatically satisfy the statutory relationship requirement.

Two-Scenario Analysis

USCIS recognizes two potential scenarios:

1. Separation: the qualifying relative remains in the United States without the applicant.
2. Relocation: the qualifying relative relocates abroad with the applicant.

An applicant may address both, but USCIS does not require proof of extreme hardship under both scenarios. The evidence should establish which outcome would actually result from denial. A detailed statement from the qualifying relative should explain whether that person would separate or relocate and why.

Hardship Factors (Per USCIS Policy Manual)

• Health conditions
• Financial considerations
• Educational needs
• Personal considerations (family ties, conditions in home country)
• Special factors (duration of residence, property ties, community ties)

QUALIFYING RELATIVE'S DECLARATION

DECLARATION OF [QUALIFYING RELATIVE FULL NAME]

I, [FULL LEGAL NAME], declare under penalty of perjury under the laws of the United States of America that the following is true and correct:

I. INTRODUCTION

1. My name is [FULL LEGAL NAME]. I am a [United States citizen / lawful permanent resident].

2. I was born on [DATE] in [CITY, STATE/COUNTRY].

3. I am the [spouse/parent/son/daughter] of [APPLICANT NAME], who is applying for a waiver of inadmissibility.

4. I reside at [ADDRESS], where I have lived for [DURATION].

5. I am submitting this declaration to explain the extreme hardship I would suffer if [APPLICANT NAME] is not permitted to [enter/remain in] the United States.

6. If the waiver is denied, I would: ☐ remain in the United States without [APPLICANT NAME] ☐ relocate to [COUNTRY] with [APPLICANT NAME] ☐ face a realistic unresolved choice between those outcomes. My reasons for that expected outcome are: [DETAILED FACTS]. I address below each scenario that is factually relevant.

II. MY RELATIONSHIP WITH [APPLICANT NAME]

7. I first met [APPLICANT NAME] on [DATE] in [LOCATION]. [Describe how you met.]

8. We began our relationship on [DATE]. [Describe development of relationship.]

9. We married on [DATE] in [LOCATION]. [If applicable. Describe marriage.]

10. We have been [married/together] for [DURATION]. [Describe the nature and depth of your relationship.]

11. [If children:] We have [NUMBER] children together: [List names, ages, citizenship status].

12. [Applicant's] role in our family includes: [Describe applicant's role - provider, caregiver, emotional support, etc.]

13. Our daily life together includes: [Describe daily interactions, shared responsibilities, routines.]

III. MY BACKGROUND

A. Employment and Financial Situation

14. I am currently employed as a [JOB TITLE] at [EMPLOYER], where I have worked since [DATE]. My annual income is approximately $[AMOUNT].

15. [If unemployed or underemployed, explain circumstances.]

16. My monthly expenses include:
    - Rent/Mortgage: $[AMOUNT]
    - Utilities: $[AMOUNT]
    - Food: $[AMOUNT]
    - Healthcare/Insurance: $[AMOUNT]
    - Transportation: $[AMOUNT]
    - Childcare: $[AMOUNT]
    - Other: $[AMOUNT]
    - Total Monthly Expenses: $[AMOUNT]

17. [APPLICANT NAME]'s contribution to our household finances includes: [Describe income, benefits, in-kind contributions.]

18. Without [APPLICANT NAME]'s contribution, I [would/would not] be able to maintain our household because: [Explain financial impact.]

B. Health Conditions

19. I have the following health conditions: [List all physical and mental health conditions]

20. [For each significant condition, describe:]
    - Diagnosis date and circumstances
    - Current treatment (medications, therapy, specialists)
    - Prognosis
    - How the condition affects daily life
    - Role of [APPLICANT NAME] in managing condition

21. [If no health conditions:] I am currently in good physical and mental health.

22. [APPLICANT NAME] assists with my health needs by: [Describe caregiver role if applicable.]

C. Education and Professional Background

23. My educational background includes: [Degrees, certifications, training]

24. My professional skills include: [List skills, especially those tied to U.S. employment]

25. [If applicable:] My professional credentials [are/are not] transferable to [COUNTRY] because: [Explain.]

IV. HARDSHIP IF I REMAIN IN THE UNITED STATES WITHOUT [APPLICANT NAME]

A. Emotional and Psychological Hardship

26. If [APPLICANT NAME] cannot be with me in the United States, I would experience significant emotional and psychological hardship because:

27. [APPLICANT NAME] provides me with [describe emotional support, companionship, stability].

28. I have [describe any history of depression, anxiety, or mental health conditions that would be exacerbated by separation].

29. [If seeing mental health professional:] My [therapist/psychologist/psychiatrist], [NAME], has diagnosed me with [CONDITION] and has stated that separation from [APPLICANT NAME] would [describe clinical opinion].

30. The prospect of being separated from [APPLICANT NAME] causes me [describe emotional distress].

31. I experienced similar emotional distress during previous separations when [describe any prior separations and their effect].

B. Financial Hardship

32. If [APPLICANT NAME] is not permitted to be in the United States, I would face significant financial hardship because:

33. Without [APPLICANT NAME]'s income of $[AMOUNT], I would not be able to afford: [List specific expenses.]

34. I would be forced to [describe potential consequences - move, reduce standard of living, incur debt, rely on public assistance, etc.].

35. [If children:] I would not be able to afford childcare, which currently costs $[AMOUNT], requiring me to [reduce work hours/leave employment].

36. [If APPLICANT provides non-financial support:] [APPLICANT NAME] currently [provides childcare/elder care/home maintenance/etc.] that I would have to pay for, costing approximately $[AMOUNT].

C. Hardship Related to Children (If Applicable)

37. Our [child/children] would suffer hardship from separation from [their father/mother] because:

38. [CHILD NAME], age [AGE], [describe relationship with applicant, applicant's role in child's life].

39. [Describe specific ways children would be harmed - behavioral issues, academic problems, emotional trauma, loss of cultural connection, etc.]

40. [If child has special needs:] [CHILD NAME] has [CONDITION] and requires [describe care needs]. [APPLICANT NAME] provides [describe care applicant provides].

D. Other Hardship from Separation

41. Additional hardship I would experience if [APPLICANT NAME] cannot be with me includes:

42. [Describe any other hardship factors - loss of caregiver for elderly relatives, impact on business, etc.]

V. HARDSHIP IF I RELOCATE TO [COUNTRY] WITH [APPLICANT NAME]

A. Safety and Country Conditions

43. If I were to relocate to [COUNTRY] with [APPLICANT NAME], I would face hardship related to conditions in that country.

44. [COUNTRY] is currently experiencing [describe relevant country conditions - violence, political instability, economic crisis, discrimination, lack of healthcare, etc.].

45. I am particularly concerned about [specific conditions that affect the qualifying relative personally].

46. As a [U.S. citizen / American / person with certain characteristics], I would face [describe specific risks or difficulties].

47. [If relevant:] [COUNTRY] has [describe conditions that would affect qualifying relative's health, safety, or ability to work].

B. Loss of Employment and Financial Hardship

48. If I relocate to [COUNTRY], I would lose my employment at [EMPLOYER], where I have worked for [DURATION] and earn $[AMOUNT].

49. My skills and credentials [describe whether they are transferable to the foreign country and why/why not].

50. The employment market in [COUNTRY] for [my profession/someone with my skills] is [describe].

51. The cost of living in [COUNTRY] compared to my potential earnings would result in [describe financial hardship].

52. I would lose the following benefits: [List retirement accounts, health insurance, pension, etc.]

C. Loss of Healthcare and Medical Treatment

53. If I relocate to [COUNTRY], I would [lose access to / have difficulty obtaining] healthcare because:

54. My current health conditions require [describe treatment, medications, specialists].

55. In [COUNTRY], [describe healthcare availability, quality, cost, access to needed treatment].

56. [If specific treatment unavailable:] The treatment I need for [CONDITION] is [not available / prohibitively expensive / of lower quality] in [COUNTRY].

57. [If applicable:] My health insurance [describe what would happen to coverage if relocating].

D. Impact on Children (If Applicable)

58. Relocation to [COUNTRY] would cause hardship to our [child/children] because:

59. [CHILD NAME] was born in the United States and has [never lived in / limited experience with] [COUNTRY].

60. [CHILD NAME] [does not speak / has limited proficiency in] [LANGUAGE], the primary language in [COUNTRY].

61. Educational opportunities in [COUNTRY] are [describe quality, availability, cost of education compared to U.S.].

62. [CHILD NAME] would lose [describe what child would lose - school, friends, activities, educational opportunities, special services].

63. [If child has special needs:] The services [CHILD NAME] requires for [CONDITION] are [not available / inadequate / prohibitively expensive] in [COUNTRY].

E. Loss of Family and Support Network

64. Relocating to [COUNTRY] would separate me from my family members in the United States, including:
    - [List family members, relationships, and proximity]

65. My [family member] depends on me for [describe caregiving or support responsibilities].

66. I would lose my support network, which currently includes: [describe friends, community, religious community, professional network].

67. I have [no / limited] family or support network in [COUNTRY].

F. Other Relocation Hardship

68. Additional hardship from relocating to [COUNTRY] includes:

69. [Describe any other factors - property in U.S., business interests, educational enrollment, cultural adjustment, religious practice, etc.]

VI. CUMULATIVE HARDSHIP

70. When considered together, the hardships described above constitute "extreme hardship" because:

71. I would suffer [summarize the most significant hardships under both scenarios].

72. The hardship I would experience goes significantly beyond what any [spouse/parent/child] would normally experience if their [family member] were denied admission.

73. [Describe any unique circumstances that make your situation particularly compelling.]

VII. SUPPORTING EVIDENCE

74. I am submitting the following evidence to support this declaration:

Identity and Relationship:
☐ Copy of my [birth certificate / passport / naturalization certificate]
☐ Copy of marriage certificate
☐ Photographs of our family

Health/Medical:
☐ Medical records documenting [CONDITIONS]
☐ Letters from treating physicians
☐ Psychological evaluation
☐ Prescription records

Financial:
☐ Tax returns for past [NUMBER] years
☐ Pay stubs
☐ Bank statements
☐ Mortgage/lease documents
☐ Monthly expense documentation

Employment:
☐ Employment verification letter
☐ Evidence of professional credentials

Country Conditions:
☐ State Department reports on [COUNTRY]
☐ Human rights reports
☐ News articles
☐ Expert declaration on country conditions

Children (if applicable):
☐ Children's birth certificates
☐ School records
☐ Medical records
☐ Letters from teachers/counselors

Other Supporting Evidence:
☐ Letters from family members
☐ Letters from mental health providers
☐ Affidavits from witnesses
☐ [Other relevant evidence]

VIII. CONCLUSION

75. For all of the reasons stated above, I believe I would suffer extreme hardship if [APPLICANT NAME] is not permitted to [enter/remain in] the United States. The documents identified in this declaration support the facts I have stated.

76. I respectfully request that USCIS grant the waiver so that [APPLICANT NAME] and I can [continue our life together / be reunited] in the United States.

If executed outside the United States: I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

If executed within the United States: I declare under penalty of perjury that the foregoing is true and correct.

Executed on [DATE] at [CITY, STATE].

_________________________________
[SIGNATURE]

_________________________________
[PRINTED NAME]

ADDITIONAL DECLARATIONS

APPLICANT'S SUPPORTING DECLARATION

[Include a declaration from the applicant corroborating the qualifying relative's statements and adding relevant information from their perspective.]

DECLARATIONS FROM THIRD PARTIES

[Include declarations from:]

• Family members
• Friends
• Employers
• Medical providers
• Mental health professionals
• Community members
• Anyone who can corroborate the hardship claims

PSYCHOLOGICAL EVALUATION SUMMARY (If Applicable)

If a psychological evaluation is submitted, it should address:

1. Evaluator's qualifications
2. Methodology and tests administered
3. Clinical findings regarding qualifying relative's mental health
4. Impact of separation on qualifying relative's mental health
5. Impact of relocation on qualifying relative's mental health
6. Prognosis under each scenario
7. Clinical prognosis under the factually expected scenario; counsel, not the clinician, should address the legal standard

HARDSHIP DECLARATION CHECKLIST

Content Requirements

☐ Qualifying relative's U.S. citizenship or LPR status established
☐ Relationship to applicant clearly explained
☐ Declarant identifies the outcome that would actually result and explains it
☐ Each factually relevant scenario is addressed; irrelevant boilerplate is deleted
☐ All relevant hardship factors addressed
☐ Specific facts and details provided (not vague or conclusory)
☐ Financial hardship documented with figures
☐ Health conditions described with treatment details
☐ Country conditions addressed with specific concerns
☐ Impact on children documented (if applicable)
☐ Cumulative hardship summarized
☐ Declaration signed under penalty of perjury

Supporting Evidence

☐ Proof of qualifying relative's status (birth certificate, naturalization certificate)
☐ Proof of relationship (marriage certificate, birth certificates)
☐ Medical records and physician letters
☐ Psychological evaluation (if applicable)
☐ Financial documents (tax returns, pay stubs, bank statements)
☐ Employment verification
☐ Country conditions evidence
☐ Letters of support from third parties
☐ Photographs (family, medical conditions if applicable)
☐ Children's records (school, medical)

Quality Control

☐ Declaration is specific and detailed
☐ Facts are consistent with other evidence
☐ No exaggeration or misrepresentation
☐ All claims are supported by evidence where possible
☐ Declaration is written in qualifying relative's voice
☐ Emotional impact is conveyed authentically
☐ Declaration is organized and easy to follow

HARDSHIP FACTORS TO ADDRESS

Health-Related Hardship

• Chronic conditions requiring ongoing treatment
• Mental health conditions (depression, anxiety, PTSD)
• Pregnancy or recent childbirth
• Disabilities
• Need for specialists unavailable abroad
• Impact of separation on mental health
• Caregiving responsibilities

Financial Hardship

• Loss of income (applicant's and/or qualifying relative's)
• Cost of maintaining two households
• Loss of health insurance
• Impact on retirement savings
• Inability to pay mortgage/rent
• Cost of childcare
• Loss of business
• Debt obligations

Educational Hardship

• Children's educational needs
• Special education services
• Language barriers abroad
• Quality of education abroad
• Disruption to education
• Loss of scholarships or opportunities

Family-Related Hardship

• Separation from children
• Separation from elderly parents
• Caregiving responsibilities
• Loss of support network
• Impact on children
• Breaking up the family unit

Country Conditions

• Violence and crime
• Political instability
• Economic conditions
• Healthcare availability
• Discrimination
• Corruption
• Natural disasters
• Lack of infrastructure

Professional Hardship

• Loss of career
• Non-transferable credentials
• Limited job market abroad
• Loss of professional network
• Starting over professionally

OFFICIAL SOURCES AND FILING CHECK

• USCIS Policy Manual, Volume 9, Part B — extreme-hardship policy, qualifying relatives, scenarios, factors, and evidence.
• Form I-601 and Form I-601A — confirm the current acceptable edition, instructions, fee, filing address, and required initial evidence on the filing date.
• 8 U.S.C. § 1182 — statutory inadmissibility and waiver provisions.
• 28 U.S.C. § 1746 — declaration language for execution within or outside the United States.

Use only with the matching current USCIS form and instructions after case-specific review by qualified immigration counsel.