Form G-146

(Expires 06/30/2007) OMB No. 1653-0020

Department of Homeland Security
U.S. Immigration and Customs Enforcement

G-146, Nonimmigrant Checkout Letter

DHS Office Address:

File Number:
Date:

The records of this office of the Department of Homeland Security show that permission was granted to
to remain in the United States for a temporary period.
This office has no record of his, her or their departure from the United States.
To assist in the completion of our records relating to the departure of temporary visitors, you are requested to
complete this form and:

[ ] Return it in the attached self-addressed envelope. No postage is required if mailed from anywhere in the United States.
[ ] Mail or take it to the office of the nearest American Consul and ask him or her to return it to this office.
Your cooperation in this matter is appreciated.
Please select and complete all parts of the statement below that accurately reflect your knowledge about this person(s).
The person(s) inquired about:

[ ] Departed from the United States at
on

Port of Departure

via

Date

Name of Vessel or other means of transportation

(NOTE: If Form I-94, Arrival-Departure Record, is available, please attach it to this form.)

[ ] Applied for or has been granted an extension of temporary stay at the

Location

Office of the Department of Homeland Security.

[ ] Applied for adjustment of status at the
Location

Office of the Department of Homeland Security.

[ ] Did not depart from the United States.
[ ] Can be contacted at the following address:
Street

City
Country

Zip Code

State or Province

[ ] Has or have the following friends or relatives in the United States who may have information concerning his, her or their
whereabouts:

Name

Address

City

State

Zip Code

Name

Address

City

State

Zip Code

Form G-146 (Rev. 12/22/03) N

[ ] None of the above items apply but the following information is provided: (Attach additional sheet(s) of paper, if necessary.)

[ ] None of the above items apply and I have no information to provide relating to this person(s).

Signature
Address
Address
Address

NOTE: The provision for collecting this information is voluntary. You are under no legal obligation to complete this form.

Paperwork Reduction Act Notice.
An agency may not conduct or sponsor an information collection and a person is not required to respond to an information
collection unless it displays a valid OMB control number. The average time to complete this collection of information is estimated as
follows: 1) learning about the form, 3 minutes; 2) completing and assembling and mailing of the form, 7 minutes, for a total of 10
minutes per response. If you have comments regarding the accuracy of this estimate or suggestions for making this form simpler,
you can write to the Department of Homeland Security; Immigration and Customs Enforcement; Office of Asset Management;
425 I St, NW, Room 1122; Washington, DC 20536; OMB No. 1653-0020. Do not mail your completed form to this address.
Form G-146 (Rev. 12/22/03) N Page 2