Form OMB 83i

PA PERW ORK REDUCTION A CT SUBM ISSION

Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork
Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation
to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street NW,
Washington, DC 20503.
1. Agency/Subagency originating request

2. OM B control nu mbe r

Department of Justice, Executive Office for Immigration Review

a.

1125

-

b.

3. Type of information collection (check one)
New collection
a.
Revision of a currently approved collection
b. ✔
c.
Extension, without change, of a currently approved collection
Reinstatement, without change, of a previously approved collection for
d.
which approval has expired
Reinstatement, with change, of a previously approved collection for which
e.
approval has expired
f.
Existing collection in use without an OMB control number

4. Type of review requested (check one)
a. ✔ Regular
Em ergency - A pproval reque sted by:
b.
c.
Delegated

3a. Public C omm ents
Has the agency received public comments on this information collection?

6. Requ ested expiration d ate
a. ✔ Three years from approval date

✔

Yes

None

0001

/

/

5. Small entities
Will this information collection have a significant economic impact on a
Yes
No
substantial number of small entities?

b.

Other Specify:

/

No

7. Title

Application for Cancellation of Removal for Certain Permanent Residents (42A); and Adjustment of Status for Certain Nonpermanent Residents (42B)
8. Agenc y form num ber(s) (if applicable)

EOIR-42A; EOIR-42B
9. Keywords

Aliens, Immigration, Cancellation, Removal
10. Abstract

This information collection is necessary to determine the statutory eligibility for cancellation of removal of individual aliens determined to be removable
from the United States and to provide information relevant to a favorable exercise of discretion.

11. Affected public (Mark primary with "P" and all others that apply with "X")
a.
b.
c.

P

d.
e.
f.

Individuals or households
Bus iness or othe r for-pro fit
Not-for-profit institutions

F a rm s
Federal Government
State, Local or T ribal Govern men t

13. Annual reporting and recordkeeping hour burden
25,654
a. Num ber of respond ents
b. Total annual responses
25,654
1.Percentage of these responses

collected electronically
0
c. Total annual hours requested 148,793
34,815
d. Current O MB inventory
9,161
e. Difference
f. Explanation of difference
1. Program change
2. Adjustment
decrease in applicants
15. Purpose of information collection
others that apply with "X")

a. P Application for be nefits
b.
Program evaluation
c.
General purpose statistics
d.
Aud it

%

(M ark prim ary with "P " an d all
e.
f.
g.

Program planning or management
Research
Regulatory or compliance

17. Statistical methods
Does this information collection employ statistical methods?
Yes

✔

No

12. Obligation to respond (Mark primary with "P" and all others that apply with "X")
a.
b.
c.

Department
Voluntary of Justice, Executive Office for Immigration Review
1125
Required to obtain or retain bene fits
0001
Mand atory

14. Annual reporting and recordkeeping cost burden (in thousands of dollars)
a. Total annualized capital/startup costs
0
b . T o ta l a nn ua l c os ts (O & M )

0
c. Total annualized cost requested

0
d. Current O MB inventory
0
e. Difference
n/a
f. Explanation of difference
1. Program change
2. Adjustment

16. Frequency of recordkeeping or reporting (check all that apply)

a.
b.
Reco rdkeeping
Third party disc losure
c. ✔ Reporting
1.
2.
3.
On occ asion
Wee kly
Mo nthly
4.
Quarterly
5.
Sem i-annually 6.
Ann ually
7.
Biennially
8. ✔ Other (de scribe) as needed
18. Agen cy contact (person who can bes t ans we r qu es tion s reg ard ing the c on ten t of this
submission)
Nam e:

Phone:

Christina Baptista

703-305-0992

02/04

OMB 83-I

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