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pdfOMB# 1125-0009
Application for Suspension of Deportation
U.S. Department of Justice
Executive Office for Immigration Review
INFORMATION FOR APPLICANT
PLEASE READ CAREFULLY. FEES WILL NOT BE RETURNED.
I. Aliens Eligible for Suspension of Deportation: You may be eligible to have your deportation suspended and to become an alien lawfully admitted to
the United States for permanent residence under former section 244 of the Immigration and Nationality Act (INA) if your deportation proceedings commenced prior to April 1, 1997. To qualify for this benefit, you must establish in a hearing before an immigration judge that:
A. You have been physically present in the United States for a continuous period of not less than seven (7) years immediately preceding the date
of this application;
NOTE: If you have been battered or subjected to extreme cruelty in the United States by your United States citizen or lawful permanent resident spouse or parent, or you are the parent of a child of a United States citizen or lawful permanent resident and the child has been battered
or subjected to extreme cruelty in the United States by such citizen or permanent resident parent, you must establish that you have maintained
continuous physical presence in the United States for three (3) or more years proceeding the date of the application.
NOTE: If you are deportable under paragraphs (2), (3), or (4) of former section 241(a) of the INA, you must establish that you have been physically present in the United States for a continuous period of not less than ten (10) years immediately following the commission of an act or assumption of a
status constituting a ground of deportation.
NOTE: If you have served on active duty in the Armed Forces of the United States for at least 24 months, you do not have to meet the requirements of
continuous physical presence in the United States. You must, however, have been in the United States when you entered the Armed Forces. If you are no
longer in the Armed Forces, you must have been separated under honorable conditions.
B. You are, and have been during the qualifying period described in “A” above, a person of good moral character as described in section 101(F)
of the INA;
C. Your deportation would result in extreme hardship to you or your United States citizen or lawful permanent resident spouse, parent, or
unmarried child under 21 years of age; and
NOTE: If you are deportable under paragraphs (2), (3), or (4) of former section 241(a) of the INA, you must establish that your deportation would result in
exceptional and extremely unusual hardship to you or your United States citizen or lawful permanent resident spouse, parent, or unmarried child under 21
years of age.
D. You are deserving of a favorable exercise of discretion.
II. Aliens NOT Eligible for Suspension of Deportation: You are not eligible for suspension of deportation if you:
A. Entered the United States as a crewman after June 30, 1964;
B. Were admitted to the United States as, or later became, a nonimmigrant exchange alien as defined in section101(a)(15)(J) of the INA in
order to receive graduate medical education or training, regardless of whether you are subject to or have fulfilled the 2-year foreign
residence requirement of section 212(e) of the INA;
C. Were admitted to the United States as, or later became, a nonimmigrant exchange alien as defined in section101(a)(15)(J) of the INA, other
than to receive graduate medical education or training, and are subject to the 2-year foreign residence requirement of section 212(e) of the
INA, but have neither fulfilled nor obtained a waiver of that requirement;
D. Are subject to deportation under former section 241(a)(4)(D) of the INA, as an alien who assisted in Nazi persecution or engaged in genocide.
E. This relief may not be available to individuals in removal proceedings.
III. How to Apply for Suspension of Deportation
If you believe that you have met all the requirements for suspension of deportation, you must answer all the questions on the attached Form EOIR-40 fully and accurately. You must pay the filing and biometrics fees and comply with the Department of Homeland Security (DHS) instructions for providing biometric and biographic information to U.S. Citizenship and Immigration Services (USCIS), (available at http://uscis.gov). You must also serve a copy of your application on the Assistant
Chief Counsel for the DHS, U.S. Immigration and Customs Enforcement (ICE) as required in the proof of service on page 8 of this application, and you must file your
application with the appropriate Immigration Court. Please read the following instructions carefully before completing your application.
Form EOIR-40
Rev. Jan. 2012
OMB# 1125-0009
U.S. Department of Justice
Executive Office for Immigration Review
Application for Suspension of Deportation
INSTRUCTIONS
1. PREPARATION OF APPLICATION.
To apply for suspension of deportation under former section 244 of the Immigration and Nationality Act (INA), you must fully and accurately answer all
questions on the attached Form EOIR-40. A separate application must be prepared and executed for each person applying for suspension of deportation.
All applications from a family unit may be submitted together and may be supported by the same documentary evidence, if applicable. An application on
behalf of an alien who is mentally incompetent or is a child under 14 years of age shall be executed by a parent or guardian.
Your responses must be typed or printed legibly in ink. Do not leave any questions unanswered or blank. If any questions do not apply to you, write
“none” or “not applicable” in the appropriate space.
To the extent possible, answer all questions directly on the form. If there is insufficient room to respond fully to a question, please continue your response
on an additional sheet of paper. Please indicate the number of the question being answered next to your response on each additional sheet, write your alien
registration number, print your name, and sign, date, and securely attach the additional sheet to the Form EOIR-40.
2. BURDEN OF PROOF.
The burden of proof is on you to prove that you meet all of the statutory requirements for suspension of deportation under former section 244 of the INA
and that you are entitled to such relief as a matter of discretion. To meet this burden, your responses to the questions on the application should be as detailed
and complete as possible. You should also attach to your application any documents that demonstrate your eligibility for suspension of deportation (see
“SUPPORTING DOCUMENTS” below).
3. SUPPORTING DOCUMENTS.
Unless you qualify through military service, you should submit documentary evidence to show that you have maintained continuous physical presence in
the United States for a required period. Documents which may show evidence of your physical presence in the United States include, but are not limited
to, bank records, leases, deeds, licenses, receipts, letters, birth records, church records, school records, employment records, and evidence of tax payments.
You should submit documents which help to show that you are and have been, a person of good moral character during the entire period of continuous
physical presence in the United States required for eligibility for suspension of deportation. You should submit police records from each jurisdiction in
which you resided during such period. To show good moral character, it is recommended that you submit the affidavits of witnesses attesting to your good moral
character, preferably citizens of the United States, and if you are employed, your employer. The affidavit from your employer should include information regarding the
nature and duration of your employment and your earnings.
You should submit official certification to establish your relationship to those you claim would suffer hardship by your removal, and if such persons are citizens of the
United States or lawful permanent residents, evidence of their citizenship or lawful permanent resident status. Documentary evidence of such relationships may include,
but are not limited to, birth records, marriage certificates, proof of divorce or termination of marriage, and death certificates.
Applicants for "Suspension of Deportation" must establish that their deportation would result in a certain level of hardship to the applicant or a family
member. If you are deportable under paragraph (2), (3), or (4) of former section 241(a), you are required to show that you or your legal permanent resident or U.S. citizen husband/wife, mother, father and/or child would suffer exceptional and extremely unusual hardship if you were deported from the
U.S. If you have been battered or subjected to extreme cruelty in the U.S. by a lawful permanent resident or U.S. citizen spouse or parent (or you are the
parent of a child of a lawful permanent resident or U.S. citizen and the child has been battered or subjected to extreme cruelty in the U.S. by that citizen
or permanent resident parent) you are required to show that your deportation would result in extreme hardship to you or your parent or child. If you are
otherwise deportable, you are required to show that you or your legal permanent resident or U.S. citizen husband/wife, mother, father and/or child would
suffer extreme hardship if you were deported from the U. S. For each of these, there are various types of hardship such as emotional, financial or medical. It is recommended that you submit certified documents, affidavits, notarized letters, and/or medical records to help prove the exceptional and extremely unusual hardship or the extreme hardship required.
You should also submit with your application copies of any documents which you were issued by the Department of Homeland Security (DHS), formerly
the Immigration and Naturalization Service. The Immigration Judge may require you to submit additional records relating to your request for suspension
of deportation. These documents may include, but are not limited to, documents which reflect payment of taxes, court convictions, or payment of child
support during your physical presence in the United States.
The original of all supporting documents must be available for inspection at the hearing. If you wish to have the original documents returned to you, you should also
present reproductions.
Form EOIR-40
Rev. Jan. 2012
OMB# 1125-0009
U.S. Department of Justice
Executive Office for Immigration Review
Application for Suspension of Deportation
4. REQUIRED BIOMETRIC AND BIOGRAPHIC INFORMATION.
Each applicant 14 years of age or older must also comply with the requirement to supply biometric and biographic information. You will be given instructions on how to complete this requirement. You will be notified in writing of the location of the Application Support Center (ASC) or the designated Law
Enforcement Agency where you must go to provide biometric and biographic information. You will also be given a date and time for the appointment. It
is important to furnish all the required information. Failure to comply with this requirement may result in a delay in your application or in your application being deemed abandoned and dismissed by the Immigration Court.
5. TRANSLATIONS.
Any document in a foreign language must be accompanied by an English language translation and a certificate signed by the translator stating that he/she
is competent to translate the document and that the translation is true and accurate to the best of the translator’s abilities. Such certification must be printed
legibly or typed.
6. PHOTOGRAPHS.
Unless you are incarcerated or detained in a facility which prevents your compliance with this instruction, you must submit two glossy, unretouched, color
photographs of yourself taken within 30 days of the date of this application. These photos must have a white background and must not be mounted. The
dimension of your facial image in the photograph should be about one (1) inch from chin to top of your hair and you should be shown in full frontal/passport-style view with your eyes open. Using a pencil or felt pen, you should lightly print your name and alien registration number on the back of each photograph.
7. FEES.
Before you file your Form EOIR-40 with the Immigration Court, you must pay the required $100 filing fee and the biometric fee to the Department of
Homeland Security (DHS). Evidence of payment of these fees in the form of a copy of the DHS, U.S. Citizenship and Immigration Services (USCIS) ASC
notice of fee receipt and biometrics appointment instructions must accompany your Form EOIR-40. These fees will not be refunded, regardless of the action
taken on your application. Therefore, it is important that you read the advice, instructions, and application carefully before responding. If you are unable to pay the
filing fee, you may ask the Immigration Judge to permit you to file your Form EOIR-40 without fee [by filing a fee waiver request (Form EOIR-26A)].
DO NOT SEND CASH. All fees must be submitted in the exact amount. Remittance may be made by personal check, cashier’s check, certified bank check,
bank international money order, or foreign draft drawn on a financial institution in the United States and payable to the “Department of Homeland Security”
in United States currency. If the applicant resides in the Virgin Islands, the check or money order must be payable to the “Commissioner of Finance of the
Virgin Islands.” If the applicant resides in Guam, the check or money order must be payable to the “Treasurer Guam.” Personal checks are accepted subject to collectibility. An uncollectible check will render the application and any documents issued pursuant thereto invalid. A charge of $30.00 will be imposed if
a check in payment of a fee is not honored by the bank on which it is drawn. When the check is drawn on an account of a person other than the applicant, the
name and alien registration number of the applicant must be entered on the face of the check. All checks must be drawn on a bank located in the United States.
8. SERVING AND FILING YOUR APPLICATION.
A. You must first comply with the DHS instructions for providing biometric and biographic information to USCIS, which involves sending a copy of
the application to the appropriate USCIS Service Center. The DHS instructions also address payment of the application fees.
B. You must then serve the following documents on the Assistant Chief Counsel for DHS, U.S. Immigration and Customs Enforcement (ICE):
- a copy of your Form EOIR-40, Application for Suspension of Deportation, with all supporting documents and additional sheets;
- a copy of the USCIS ASC notice of fee receipt and biometrics appointment instructions;
- the original Biographical Information Form G-325A; and
- a photograph of you which meets the requirements of instruction #6 above.
You must file the following documents with the appropriate Immigration Court:
- the original Form EOIR-40 with all supporting documents and additional sheets;
- a copy of the USCIS ASC notice of fee receipt and biometrics appointment instructions;
- a copy of Biographical Information Form G-325A;
- a photograph of you which meets the requirements of instruction #6 above; and
- a completed certificate showing service of these documents (See Part 10 of the Application on page 8) on the ICE Assistant Chief Counsel, unless
service is made on the record at the hearing.
Retain your USCIS ASC biometrics confirmation document or a copy of your Fingerprint Card, FD-258, if applicable, as proof that your biometrics were taken, and
bring it to your future Immigration Court hearings.
Form EOIR-40
Rev. Jan. 2012
OMB# 1125-0009
U.S. Department of Justice
Executive Office for Immigration Review
Application for Suspension of Deportation
9. PENALTIES.
You must answer all questions on Form EOIR-40 truthfully and submit only genuine documents in support of your application. You will be required to swear or
affirm that the contents of your application and the supporting documents are true to the best of your knowledge. Your answer to the questions on this form
and the supporting documents you present will be used to determine whether your deportation should be suspended and whether you should be granted permanent
resident status. Any answer you give and any supporting document you present may also be used as evidence in any proceeding to determine your right to be admitted or readmitted, re-enter, pass through, or reside in the United States. Your application may be denied if any of your answers or supporting documents are found
to be false.
Presenting false answers or false documents may also subject you to criminal prosecution under 18 U.S.C. section 1546 and/or subject you to civil
penalties under 8 U.S.C. section 1324c if you submit your application knowing that the application, or any supporting document, contains any false
statement with respect to a material fact, or if you swear or affirm that the contents of your application and the supporting documents are true, knowing that the application or any supporting documents contain any false statement with respect to a material fact. If convicted, you could be fined up to
$250,000, imprisoned for up to ten (10) years, or both. 18 USC sections 1546(a), 3559(a)(4), 3571(b)(3). If it is determined you have violated the prohibition against document fraud and a final order is entered against you, you could be subject to a civil penalty up to $2,000 for each document used
or created for the first offense, and up to $5,000 for any second, or subsequent offense. In addition, if you are the subject of a final order for violating
8 U.S.C. section 1324c, relating to civil penalties for document fraud, you will be removable from the United States.
10. PAPERWORK REDUCTION ACT NOTICE.
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a current valid OMB control number.
We try to create forms and instructions that are accurate, can easily be understood, and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. The reporting burden for this collection of information is computed as
follows: 1) learning about the form, 45 minutes, 2) completing the form, 2 hours, and 3) assembling and filing the form, 3 hours, for an average of 5 hours,
45 minutes per application. If you have comments regarding the accuracy of this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, you may write to the U.S. Department of Justice, Executive Office for Immigration Review, Office of the
General Counsel, 5107 Leesburg Pike, Suite 2600, Falls Church, Virginia 22041.
11. PRIVACY ACT NOTICE.
The information on this form is authorized by former 8 U.S.C. § 1254 in order to apply for Suspension of Deportation. The information you provide is mandatory and required to obtain the relief of Suspension of Deportation. Failure to provide the requested information may result in denial of your request. EOIR
may share this information with others in accordance with approved routine uses described in EOIR's system of records notice EOIR-001, Records and
Management Information System.
Form EOIR-40
Rev. Jan. 2012
OMB# 1125-0009
Application for Suspension of Deportation
U.S. Department of Justice
Executive Office for Immigration Review
(Under former Section 244 of the
PLEASE READ ADVICE AND INSTRUCTIONS
BEFORE FILLING IN FORM
Immigration and Nationality Act)
Fee Stamp (Official Use Only)
PLEASE TYPE OR PRINT
PART 1 - INFORMATION ABOUT YOURSELF
1) My present true name is: (Last, First, Middle)
2) Alien Registration or “A” Number(s):
3) My name given at birth was: (Last, First, Middle)
4) Birth Place: (CIty and Country)
5) Date of Birth: (Month, Day, Year)
7) Height:
6) Gender:
❏ Male
10) a) Current Nationality:
b) Current Citizenship:
8) Hair Color:
9) Eye Color:
❏ Female
11) Social Security Number:
12) Home Phone Number:
(
14) I currently reside at:
)
12) Work Phone Number:
(
)
15) I have been known by these additional name(s):
Apt. number and/or in care of
Number and Street
City or Town
State
Zip Code
16) I have resided in the following locations in the United States: (List PRESENT ADDRESS FIRST, and work back in time for at least 10 years).
Street and Number - Apt. or Room# - City or Town - State - Zip Code
Resided From:
Resided To:
(Month, Day, Year)
(Month, Day, Year)
PRESENT
Please continue answers on a separate sheet as needed.
(1)
Form EOIR-40
Rev. Jan. 2012
PART 2 - INFORMATION ABOUT THIS APPLICATION
17) I, the undersigned, hereby request that my deportation be suspended under the provisions of former section 244 of the Immigration and Nationality Act
(INA). I believe that I am eligible for suspension of deportation because such deportation would result in extreme hardship (or exceptional and
extremely unusual hardship if I am subject to deportation under section 241(a)(2), (3), or (4) of the INA) to: (Place a C in the box if the family member
is a citizen of the United States, an L if the family member is a lawful permanent resident of the United States, an X if the family member is neither,
and leave BLANK if not applicable.)
❏ Myself
(and/or my)
❏
❏ Wife
Husband
❏
Father
❏
❏
Mother
Child or Children.
Please state the basis for your claim that your deportation would result in extreme hardship to each of the individuals checked in the boxes
above:
❏ I, or my child, have been battered or subjected to extreme cruelty by a United States citizen or lawful permanent resident spouse
or parent.
With the exception of the absences described in question #23, I have resided in the United States since:
(Month, Day, Year)
.
PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES
18) I first arrived in the United States under the name of: (Last, First, Middle)
19) I first arrived in the United States on: (Month, Day, Year)
20) Place or port of first entry: (Place or Port, City, and State)
21) I:
a)
❏
was inspected and admitted.
❏
I entered using my Lawful Permanent Resident card which is valid until
.
(Month, Day, Year)
❏
I entered using a
visa which is valid until
(Specify Type of Visa)
b)
❏
was not inspected and admitted.
❏
❏
c)
❏
.
(Month, Day, Year)
I entered without documents. Explain:
.
I entered without inspection. Explain:
.
Other Explain:
22) I applied on
.
for additional time to stay and it was
❏
granted on
(Month, Day, Year)
(Month, Day, Year)
and valid until
, or
❏
denied on
.
(Month, Day, Year)
(Month, Day, Year)
23) Since the date of my first entry, I departed from and returned to the United States at the following places and on the following dates:
(Please list all departures regardless of how briefly you were absent from the United States.)
If you have never departed from the United States since your original date of entry, please mark an X in the box: ❏
1
Port of Departure (Place or Port, City and State)
Departure Date (Month, Day, Year)
Purpose of Travel
Port of Return (Place or Port, City and State)
Return Date (Month, Day, Year)
Manner of Return
Destination
Inspected and Admitted?
❏ Yes ❏
2
No
Port of Departure (Place or Port, City and State)
Departure Date (Month, Day, Year)
Purpose of Travel
Destination
Port of Return (Place or Port, City and State)
Return Date (Month, Day, Year)
Manner of Return
Inspected and Admitted?
24) Have you ever departed the United States:
❏ Yes ❏ No
a) under an order of deportation, exclusion, or removal?.............................................❏ Yes ❏ No
b) pursuant to a grant of voluntary departure? ............................................................ ❏ Yes ❏ No
c) voluntarily, other than by a grant of voluntary departure? ...................................... ❏ Yes ❏ No
Please continue answers on a separate sheet as needed.
(2)
Form EOIR-40
Rev. Jan. 2012
PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE
25) a) I am not married:
b) I am married:
26) If married, the name of my spouse is: (Last, First, Middle)
❏
27) Date of Marriage: (Month, Day, Year)
❏
c) I have a common-law spouse:
❏
28) The marriage took place in: (City and Country)
29) Birth place of spouse: (City and Country)
30) My spouse currently resides at:
31) Birth Date of Spouse: (Month, Day, Year)
Apt. number and/or in care of
32) My spouse is a citizen of: (Country)
Number and Street
City or Town
State/Country
Zip Code
33) If your spouse is other than a native born United States citizen, answer the following:
a) He/she arrived in the United States at: (Place or Port, City and State)
.
b) He/she arrived in the United States on: (Month, Day, Year)
.
.
c) His/her alien registration number is: A#
at
d) He/she was naturalized on (Month, Day, Year)
.
(City and State)
34) My spouse
❏
- is
❏
- is not employed. If employed, please give salary and the name and address of the spouse’s place(s) of employment.
Full Name and Address of Spouse’s Employer
Earnings Per Week
(Approximate)
$
$
$
35) I ❏ - have ❏ - have not been previously married: (If previously married, list the name of each prior spouse, the dates on which each marriage
began and ended, the place where the marriage terminated, and describe how each marriage ended.)
Name of prior spouse: (Last, First, Middle)
Date marriage began:
Date marriage ended:
Place marriage ended:
Description or manner of how marriage was
terminated or ended:
(City and Country)
36) My present spouse ❏ - has ❏ - has not been previously married: (If spouse was previously married, list the name of each prior spouse, the dates
on which the marriage began and ended, the place where the marriage terminated, and describe how each marriage ended.)
Place marriage ended:
Name of spouse’s prior spouse: (Last, First, Middle) Date marriage began:
Date marriage ended:
(City and Country)
Description or manner of how marriage was
terminated or ended:
37) Have you been ordered by any court, or are otherwise under any legal obligation, to provide child support and/or spousal maintenance as a result of
a separation and/or divorce?
❏ - Yes ❏ - No
PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS (Continued on page 4)
38) Since my first entry into the United States, I have been employed by the following named persons or firms: (Please begin with present employment and
work back in time. Any periods of unemployment or school attendance should be specified. Attach a separate sheet for additional entries, if necessary.)
Full Name and Address of Employer
Earnings Per Week
(Approximate)
Type of Work
Performed
$
Employed From:
Employed To:
(Month, Day, Year)
(Month, Day, Year)
PRESENT
$
$
Please continue answers on a separate sheet as needed.
(3)
Form EOIR-40
Rev. Jan. 2012
PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS (Continued from page 3)
39) If self-employed, describe the nature of the business, the name of the business, its address, and net income derived therefrom:
40) My assets (and if married, my spouse’s assets) in the United States and other countries, not including clothing and household necessities, are:
Self
Cash, Stocks, and Bonds...................................... $
Real Estate (dollar value minus amount owed)...$
Auto (dollar value minus amount owed) ............ $
Other (describe on line below)............................ $
TOTAL $
Jointly Owned With Spouse
Cash, Stocks, and Bonds...................................... $
Real Estate (dollar value minus amount owed)...$
Auto (dollar value minus amount owed) ............ $
Other (describe on line below)............................ $
TOTAL $
41) I ❏ - have ❏ - have not received public or private relief or assistance (e.g., Welfare, Unemployment Benefits, Medicaid, TANF, AFDC, Housing
Subsidies and WIC Benefits etc.). If you have, please give full details including the type of relief or assistance received, date for which relief or assistance was
received, place, and amount received during this time:
42) Please list each of the years in which you have filed an income tax return with the Internal Revenue Service:
43) Members of my family, including my spouse and/or child(ren) ❏ -have ❏ -have not received public or private relief or assistance (e.g., Welfare,
Unemployment Benefits, Medicaid, TANF, AFDC, etc.). If any member of your immediate family has received such relief or assistance, please give
full details including identity of person(s) receiving relief or assistance, dates for which relief or assistance was received, place, and total amount
received during this time:
Name of Child: (Last, First, Middle)
Child’s Alien Registration Number:
A#:
Estimated Total of Assets: $
A#:
Estimated Total of Assets: $
A#:
Estimated Total of Assets: $
Citizen of What Country:
Birth Date: (Month, Day, Year)
Now Residing At: (City and Country)
Birth Place: (City and Country)
Male
Estimated Avg. Weekly Earnings: $
Female
Male
Estimated Avg. Weekly Earnings: $
Female
Male
Estimated Avg. Weekly Earnings: $
Immigration Status
of Child?
Sex
Female
❏
❏
❏
❏
❏
❏
44) If your application is denied, would your spouse and all of your children accompany you to your:
a) Country of Birth -
❏ Yes ❏ No, b) Country of Nationality - ❏ Yes ❏
No, and/or c) Country of Last Residence -
❏ Yes ❏ No.
If you answered “NO” to any of the responses, please explain:
45) Describe in detail what specific hardship you or each of your United States Citizen or lawful permanent resident spouse, parent or unmarried child
under 21 years of age would suffer if you were deported :
Please continue answers on a separate sheet as needed.
(4)
Form EOIR-40
Rev. Jan. 2012
PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued from page 4)
46) Members of my family, including my spouse and/or child(ren) ❏ -have ❏ -have not received public or private relief or assistance (e.g., Welfare,
Unemployment Benefits, Medicaid, TANF, AFDC, Housing Subsidies and WIC Benefits, etc.). If any member of your immediate family has received
such relief or assistance, please give full details including identity of person(s) receiving relief or assistance, dates for which relief or assistance was
received, place, and total amount received during this time:
47) Please give the requested information about your parents, brothers, sisters, aunts, uncles, and grandparents, living or deceased. As to residence, show
street address, city, and state, if in the United States; otherwise show only country:
Name: (Last, First, Middle)
Alien Registration Number:
Citizen of What Country:
Birth Date: (Month, Day, Year)
A#:
/
Complete Address of Current Residence, if living:
/
A#:
/
Complete Address of Current Residence, if living:
/
Immigration Status
of Listed Relative
Relationship to Me:
Birth Place: (City and Country)
IF THIS APPLICATION IS BASED ON HARDSHIP TO A PARENT OR PARENTS, QUESTIONS 49-52 MUST BE ANSWERED.
48) If your parent is not a citizen of the United States, give the date and place of arrival in the United States, including full details as to the date,
manner, and terms of admission into the United States:
49) My father
❏ -is ❏
-is not employed. If employed, please give salary and the name and address of the place(s) of employment.
Full Name and Address of Employer
Earnings Per Week
(Approximate)
$
50) My mother ❏ -is
❏ -is not employed.
If employed, please give salary and the name and address of the place(s) of employment.
Full Name and Address of Employer
Earnings Per Week
(Approximate)
$
51) My parent’s assets in the United States and other countries not including clothing and household necessities are:
Assets of father consist of the following:
Assets of mother consist of the following:
Cash, Stocks, and Bonds...................................... $
Cash, Stocks, and Bonds...................................... $
Real Estate (dollar value minus amount owed)...$
Real Estate (dollar value minus amount owed)...$
Auto (dollar value minus amount owed) ............ $
Auto (dollar value minus amount owed) ............ $
Other (describe on line below)............................ $
Other (describe on line below)............................ $
TOTAL $
TOTAL $
PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6)
52) I
53) I
❏ - have ❏ -have not been admitted as, or after arrival in the United States acquired the status of, an exchange alien.
❏ - have ❏ -have not submitted address reports as required by section 265 of the Immigration and Nationality Act.
Please continue answers on a separate sheet as needed.
(5)
Form EOIR-40
Rev. Jan. 2012
PART 7 - MISCELLANEOUS INFORMATION (Continued from page 5)
54) I ❏ - have ❏ -have never (either in the United States or in any foreign country) been arrested, summoned into court as a defendant, convicted,
fined, imprisoned, placed on probation, or forfeited collateral for an act involving a felony, misdemeanor, or breach of any public law or ordinance
(including, but not limited to, traffic violations or driving incidents involving alcohol). (If answer is in the affirmative, please give a brief
description of each offense including the name and location of the offense, any penalty imposed, any sentence imposed, and the time actually served.)
55) Have you ever served in the Armed Forces of the United States?
service number.
❏ -Yes ❏ -No.
If “Yes,” please state branch (Army, Navy, etc.) and
Place of entry on duty: (City and State)
Date of entry on duty: (Month, Day, Year)
Date of discharge: (Month, Day, Year)
Type of discharge: (Honorable, Dishonorable, etc.)
I served in active duty status from: (Month, Day, Year)
to
(Month, Day, Year)
56) Have you ever left the United States or the jurisdiction of the district where you registered for the draft to avoid being drafted into the military or
naval forces of the United States?
❏ Yes ❏ No
57) Have you ever deserted from the military or naval forces of the United States while the United States was at war?
58) If male, did you register under the Military Selective Service Act or any applicable Selective Service (Draft) Laws?
If “Yes,” please give date, Selective Service number, local draft board number, and your last draft classification:
59) Were you ever exempted from service because of conscientious objection, alienage, or any other reason?
❏
Yes
❏
Yes
❏
❏
❏
Yes
No
❏
No
No
60) Please list your present or past membership in or affiliation with every political organization, association, fund, foundation, party, club, society, or
similar group in the United States or any other place since your 16th birthday. Include any foreign military service in this part. If none, write “None.”
Include the name of the organization, location, nature of the organization, and the dates of membership.
Name of Organization
Location of Organization
Nature of Organization
Please continue answers on a separate sheet as needed.
(6)
Member From:
Member To:
(Month, Day, Year)
(Month, Day, Year)
Form EOIR-40
Rev. Jan. 2012
PART 7 - MISCELLANEOUS INFORMATION
(Continued from page 6)
61) Have you ever:
a)
b)
❏ Yes ❏ No
❏ Yes ❏ No
c)
❏
Yes
❏
No
been ordered deported, excluded, or removed?
overstayed a grant of voluntary departure from an Immigration Judge or the Department of Homeland Security (DHS),
formerly the Immigration and Naturalization Service (INS)?
failed to appear for deportation?
62) Have you ever been:
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏
❏
❏
❏
❏
❏
❏
❏
No
a habitual drunkard?
No
one whose income is derived principally from illegal gambling?
No
one who has given false testimony for the purpose of obtaining immigration benefits?
No
one who has engaged in prostitution or unlawful commercialized vice?
No
involved in a serious criminal offense and asserted immunity from prosecution?
No
a polygamist?
No
one who aided and/or abetted another to enter the United States illegally?
No
a trafficker of controlled substance, or a knowing assister, abettor, conspirator, or colluder with others in any such
Yes
inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?
Yes
❏
❏
No
j)
❏
❏
No
one who has ordered, incited, assisted, or otherwise participated in the persecution of an individual on account of his or
k)
❏
Yes
❏
No
a person previously granted relief under former sections 212(c) or 244(a) of the INA or whose removal has previously
a)
b)
c)
d)
e)
f)
g)
h)
controlled substance offense (not including a single offense of simple possession of 30 grams or less of marijuana)?
i)
her race, religion, nationality, membership in a particular social group, or political opinion?
been cancelled under section 240A of the INA?
If you answered “Yes” to any of the above questions, explain:
63) Are you the beneficiary of an approved visa petition? ❏ Yes ❏ No
If yes, can you arrange a trip outside the United States to obtain an immigrant visa?
❏
Yes
❏
No
If no, please explain:
64) The following certificates or other supporting documents are attached hereto as a part of this application: (Refer to the Instructions for
documents which should be attached.)
Please continue answers on a separate sheet as needed.
(7)
Form EOIR-40
Rev. Jan. 2012
PART 8 - SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT
(Read the following information and sign below.)
I declare that I have prepared this application at the request of the person named in Part 1, that the responses provided are based on
all information of which I have knowledge, or which was provided to me by the applicant, and that the completed application was
read to the applicant in a language the applicant speaks fluently for verification before he or she signed the application in my presence. I am aware that the knowing placement of false information on the Form EOIR-40 may subject me to civil penalties under 8
U.S.C. 1324c.
Signature of Preparer:
Daytime Telephone #:
(
Print Name:
Date:
Address of Preparer: (Number and Street, City, State, Zip Code)
)
PART 9 - SIGNATURE
APPLICATION NOT TO BE SIGNED BELOW UNTIL APPLICANT APPEARS BEFORE
AN IMMIGRATION JUDGE
I swear or affirm that I know the contents of this application that I am signing, including the attached documents and supplements, and that they
are all true to the best of my knowledge, taking into account the correction(s) numbered
to
, if any, that were made by me or at
my request.
(Signature of Applicant or Parent or Guardian)
Subscribed and sworn to before me by the above-named applicant at
Immigration Judge
Date (Month, Day, Year)
PART 10 - PROOF OF SERVICE
I hereby certify that a copy of the foregoing Form EOIR-40 was:
❏
- delivered in person
❏
- mailed first class, postage prepaid
to the Assistant Chief Counsel for the DHS (U.S. Immigration and Customs Enforcement - ICE)
on
(Month, Day, Year)
at
(Number and Street, City, State, Zip Code)
Signature of Applicant (or Attorney or Representative)
Please continue answers on a separate sheet as needed.
(8)
Form EOIR-40
Rev. Jan. 2012
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 2012-02-13 |