Form I-356 Request for Cancellation of a Public Charge Bond

Request for Cancellation
of Public Charge Bond

USCIS
Form I-356

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-xxxx
Expires xx/xx/20xx

For USCIS Use Only
Bar Code Area

Action Block

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Initial Receipt

Resubmitted

Relocated

Received

Sent

Bond is

Breached
Cancelled
Continued

Comments (if needed):

To be Completed by the Obligor and Agent/Co-obligor's Attorney or Accredited Representative (if any).
Select this box if
Form G-28

Volag Number
(if any)

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

To be Completed by the Alien's Attorney or Accredited Representative (if any).

Select this box if
Form G-28

Volag Number
(if any)

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Obligor and Agent/Co-Obligor Information (To Be Completed by the Obligor or Agent/Co-Obligor)
Provide the following information.

Information About Obligor
1.

Name of Obligor

2.

Mailing Address
In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code
(USPS ZIP Code Lookup)

Form I-356 09/26/18

Page 1 of 13

Part 1. Obligor and Agent/Co-Obligor Information (To Be Completed by the Obligor or Agent/Co-Obligor)
(continued)
3.

Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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4.

Daytime Telephone Number

6.

Taxpayer Identification Number (TIN) (includes ITIN, EIN and SSN)

5.

Email Address (if any)

Information About Agent/Co-Obligor
7.

Name of Agent/Co-Obligor (if any-Surety Bonds only)

8.

Mailing Address

In Care Of Name (if any)

9.

Street Number and Name

Apt. Ste. Flr.

City or Town

State

Number

ZIP Code

Physical Address (if different from that of Obligor)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

10.

Daytime Telephone Number

12.

Taxpayer Identification Number (TIN) (includes ITIN, EIN and SSN)

13.

Power of Attorney Number

11.

ZIP Code

Email Address (if any)

Information About Bond
14.

Bond Receipt Number
►

Form I-356 09/26/18

15.

Bond Amount
$

Page 2 of 13

Part 1. Obligor and Agent/Co-Obligor Information (To Be Completed by the Obligor or Agent/Co-Obligor)
(continued)
16.

Date when Department of Homeland Security (DHS) approved and accepted the bond as
shown in Section D of the Public Charge Bond (Form I-945) (mm/dd/yyyy)

Part 2. Obligor's or Agent/Co-Obligor's Statement, Contact Information, Certification, and Signature
(To Be Completed By the Obligor or Agent/Co-Obligor)
1.

Choose the appropriate statement and sign.
A.

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The Alien Naturalized, Permanently Departed the United States, or Died
I (Name of the Obligor)

, or I (Name of the Agent/Co-Obligor)

acting on behalf of (Name of the Obligor)

,

, request that the public charge bond

executed on Form I-945 on behalf of (Name of the Alien)
born on (Alien Date of Birth (mm/dd/yyyy))

,

, and residing at

(Address of the Alien)

be cancelled and that (Name of the Obligor)

,

, and (Name of the Agent/

Co-Obligor, if any)
, be released from all liabilities imposed by the conditions of
the bond because the alien either naturalized, permanently departed the United States, or died, and the conditions of
the bond, as outlined in 8 CFR 213.1 are otherwise met, including that the alien has not received any public benefits,
as defined in 8 CFR 212.21(b), after the alien's adjustment of status to that of a lawful permanent resident and until
this bond is cancelled.
B.

Cancellation Following The Alien's 5th Anniversary of the Alien's Admission as a Lawful Permanent Resident
I (Name of the Obligor)

, or I (Name of the Agent/Co-Obligor)

acting on behalf of (Name of the Obligor)

,

, request that the public charge bond

executed on Form I-945 on behalf of (Name of the Alien)
born on (Alien Date of Birth (mm/dd/yyyy))

,

, and residing at

(Address of the Alien)

,

be cancelled because it is past the alien's fifth anniversary of the admission as a lawful permanent resident and the
conditions of the bond, as outlined in 8 CFR 213.1, are otherwise met, including that the alien has not received public
benefits, as defined in 8 CFR 212.21(b) since the alien's adjustment of status to that of a lawful permanent resident
and preceding the 5th anniversary of the Alien's Adjustment of Status.
C.

The Alien Obtained An Immigration Status That is Exempt From Public Charge Grounds of Inadmissibility
under INA section 212(a)(4)Following the Initial Grant of Lawful Permanent Resident Status
I (Name of the Obligor)

, or I (Name of the Agent/Co-Obligor)

acting on behalf of (Name of the Obligor)

, request that the public charge bond

executed on Form I-945 on behalf of (Name of the Alien)
born on (Alien Date of Birth (mm/dd/yyyy))

,

,
, and residing at

(Address of the Alien)

,

be cancelled and that (Name of the Obligor)

,

Form I-356 09/26/18

Page 3 of 13

Part 2. Obligor's or Agent/Co-Obligor's Statement, Contact Information, Certification, and Signature
(To Be Completed By the Obligor or Agent/Co-Obligor) (continued)
be released from all liabilities imposed by the conditions of the bond because the alien has obtained an immigration
status that is exempt from public charge grounds of inadmissibility under INA section 212(a)(4), following the
initial grant of the alien's adjustment of status to that of a lawful permanent resident, and the conditions of the bond,
as outlined in 8 CFR 213.1, are otherwise met, including that the alien has not received public benefits, as defined in
8 CFR 212.21(b), after the alien's adjustment of status to that of a lawful permanent resident and until he or she
obtained the new status that is exempt from public charge.

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Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the
release of any information from any and all of my records that USCIS may need to determine whether the conditions
of the bond are met and that the bond can be cancelled. I furthermore authorize release of information contained in
this form, in supporting documents, and in USCIS records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I certify, under penalty of perjury, that all of the information in Parts 1. and 2. of this Form I-356 and any document
submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained
in, and submitted with, Parts 1. and 2. of Form I-356, and that all of this information is complete, true, and correct.
2.

Signature of Obligor

Date of Signature (mm/dd/yyyy)

3.

Signature of Agent/Co-Obligor (if any)

Date of Signature (mm/dd/yyyy)

Part 3. Information About the Alien for Whom the Public Charge Bond Was Issued (To Be Completed
By the Alien or the Alien's Executor)
1.

Alien Registration Number (A-Number) (if any)
►

A-

U.S. Social Security Number (SSN) (if any)
►

3.

USCIS Online Account Number (if any)
►

4.

Current Legal Name

Family Name (Last Name)

5.

2.

Given Name (First Name)

Middle Name

Given Name (First Name)

Middle Name

Other Names You May Have Used Since Birth
Family Name (Last Name)

6.

Gender

8.

Place of Birth
City or Town

Male

Female

7.

Date of Birth (mm/dd/yyyy)

State or Province

Country

Form I-356 09/26/18

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Part 3. Information About the Alien for Whom the Public Charge Bond Was Issued (To Be Completed
By the Alien or the Alien's Executor) (continued)
9.

Country of Citizenship or Nationality

10.

Mailing Address
In Care Of Name (if any)

11.

Apt. Ste. Flr.

City or Town

State

Physical Address

Apt. Ste. Flr. Number

City or Town

State

Postal Code

Number

ZIP Code

Street Number and Name

Province

12.

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Street Number and Name

ZIP Code

Country

Past Residences. List all your past residences since you became a Lawful Permanent Resident (LPR). Start with the most recent
residence. If you need extra space to complete this section, use the space provided in Part 9. Additional Information.
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-356 09/26/18

ZIP Code

ZIP Code

Page 5 of 13

Part 4. Cancellation of the Bond Because of Alien's U.S. Citizenship, Permanent Departure, Death (To
Be Completed By the Alien or the Alien's Executor) or Following the Alien's 5th Anniversary After the
Alien's Admission as a Lawful Permanent Resident (To be Completed by the Alien or the Alien's Executor)
Answer the following questions below and provide the requested information. You should indicate whether any of the circumstances
addressed in the questions have occurred since the date DHS accepted the public charge bond that was submitted on your behalf. If you
are the Executor of the deceased alien's estate, answer these questions on behalf of the deceased alien.
1.

Yes

Have you become a United States citizen?

No

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If you answered “Yes,” please provide the information requested.

2.

A.

Certificate of Naturalization Number (if applicable)

B.

Date of Naturalization (if applicable)
(mm/dd/yyyy)

C.

Citizenship Certificate Number (if applicable)

D.

Date When Citizenship Was Derived (if applicable)
(mm/dd/yyyy)

E.

U.S. Passport Number (if applicable)

F.

Date When Passport Issued (if Applicable)
(mm/dd/yyyy)

Have you permanently departed the United States because you physically departed the United States and you voluntarily
abandoned your lawful permanent resident status as evidenced by you having submitted Form I-407 to the U.S. Government?
(This includes departures from the United States while removal proceedings were ongoing, and subsequent submission of Form
I-407 to the United States Government).
Yes
No
If you answered “No,” go to Item E. If you answered “Yes,” please provide the following information in Items. A. - D.
A.

Date of last Departure from the United States
(mm/dd/yyyy)

C.

Date When Record of Abandonment of Lawful Permanent Resident Status (Form I-407) was filed

D.

Place where Form I-407 (USCIS International Office, U.S. Embassy/Consular Section/ Port of Entry) was filed Attach
copy of Form I-407 (if available) and any documentation you received.

E.

Have you permanently departed the United States because you were removed, excluded, or deported (that is, you had an
order of removal and were physically removed from the United States or your departed on your own after you had an
order of removal, exclusion or deportation) or because you departed after you were granted voluntary departure (under
INA 240B)?
Yes
No

B.

Place of Departure

If you answered “No,” go to Item Number 4. If you answered “Yes,” please provide the following information in Items
F. - H. Also include a copy of your removal, exclusion, deportation, or voluntary departure order. If you departed
according to a voluntary departure order, include proof that you departed according to the terms of your voluntary
departure order.
F.

Date of the Removal, Exclusion, Deportation, or Voluntary Departure Order (mm/dd/yyyy)

G.

Date of Removal, Exclusion, or Deportation, or Voluntary Departure (mm/dd/yyyy)

H.

Place of Departure/Removal, Exclusion or Deportation

Form I-356 09/26/18

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Part 4. Cancellation of the Bond Because of Alien's U.S. Citizenship, Permanent Departure, Death (To
Be Completed By the Alien or the Alien's Executor) or Following the Alien's 5th Anniversary After the
Alien's Admission as a Lawful Permanent Resident (To be Completed by the Alien or the Alien's Executor)
(continued)
3.

Has the alien on whose behalf a bond has been issued died?

Yes

No

If you answered “No,” go to Item Number 5. If you answered “Yes,” please provide the information in Items A. - B. about the
alien's death and attach a certified copy of the alien's death certificate:
A.

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Date of Death (mm/dd/yyyy)

B.

Death Certificate Number (please attach an official copy of the death certificate)

4.

Information about the person completing Item Number 3. on behalf of the deceased alien (Please attach a certified copy that
establishes your legal authority to act on behalf of the alien's estate):

5.

Full Name

Family Name (Last Name)

6.

Mailing Address

Given Name (First Name)

Middle Name

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

7.

Physical Address

Postal Code

ZIP Code

Country

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

8.

Daytime Telephone Number

9.

10.

Relationship to Deceased

11.

Have you been a lawful permanent resident for at least five years?

Email Address (if any)

Yes

No

If you answered “Yes,” please provide the information about when you became a lawful permanent resident below.
Date When You Became a Lawful Permanent Resident (mm/dd/yyyy)

Form I-356 09/26/18

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Part 5. Cancellation of the Bond If Alien Obtains Immigration Status Exempt from Public Charge
Inadmissibility under INA section 212(a)(4) Following the Initial Grant of Status as a Lawful Permanent
Resident (To be Completed by the Alien)
Answer the following questions below and provide the requested information.
1.

When did you lose or relinquish your lawful permanent resident status for which the public charge bond was posted? Provide
the appropriate documentation.
Date (mm/dd/yyyy)

2.

Did you lose your status in removal proceedings or did you give up your lawful permanent resident status through other means?

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Please check one option.

I lost my LPR status in removal proceedings. Please proceed to Item Number 3.
I gave up status through means other than removal proceedings.

In the space below, please explain how and why you gave up your LPR status. Then, proceed to Item Number 4.

3.

4.

Please provide the following information about removal, exclusion or deportation proceedings in which you lost your lawful
permanent resident status (for which the public charge bond was posted). Please attach any communication that you received
from the immigration authorities, if available.
A.

Date of the Removal, Exclusion, Deportation (mm/dd/yyyy)

B.

Place of Removal Proceedings (Name and Location of the Immigration Court)

Provide the requested information about your current immigration status (Please also provide documentary evidence of your
current immigration status).
A.

Current Immigration Status

B.

Receipt number for the application you submitted in connection
with your current immigration status (if any)

C.

Date when you were granted your current
immigration status (mm/dd/yyyy)

►
D.

DHS or DOS
Place and Location

EOIR
Place and Location

Form I-356 09/26/18

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Part 6. Alien's Receipt of Public Benefits since DHS' Acceptance of the Public Charge Bond (To be
Completed by the Alien or the Alien's Executor (if the Alien is Deceased))
Please provide the following information about your (the alien's) receipt of public benefits since you were granted adjustment of status
to that of a lawful permanent resident. See the Instructions for a definition of public benefits.
1.

Since you were granted adjustment of status to that of a lawful permanent resident, have you received any public benefits, as
listed in the Instructions?
Yes
No

If you answered “Yes,” provide information about the public benefits below. If you need additional space to complete any Item
Number in this Part, use the space provided in Part 10. Additional Information.
Type of Benefit

2.

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Amount of Benefit

weekly
monthly
annually

other
explain

weekly
monthly
annually

other
explain

weekly
monthly
annually

other
explain

Agency
That Granted
Benefit

Date
Benefit Was
Granted

Date Benefit
Ended or
Expires
(mm/dd/yyyy)

Number of
Household
Members
Receiving the
Benefits (If
applicable)

If you answered “Yes” in Item Number 1, and provided information about the public benefits in the table, did you receive any
of the benefits while you were serving in active duty or in the Ready Reserve component of the U.S. Armed Forces, or while
you were the spouse or child of such a service member?
Yes
No
If you answered “Yes” please provide the information requested in the instructions.

Part 7. Alien's (or Alien Executor's) Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-356 Instructions before completing this section.

Alien's (or the Alien's Executor's) Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2.
1.

Alien's (or the Alien's Executor's) Statement Regarding the Interpreter
A.

I can read and understand English, and I have read and understand every question and instruction in my portion of
Form I-356 and my answer to every question.

B.

The interpreter named in Part 7 read to me every question and instruction in my portion of the Form I-356 and my
answer to every question in

, a language in which I am fluent,

and I understood everything.
2.

Alien's (or the Alien's Executor's) Statement Regarding the Preparer
At my request, the preparer named in Part 8.,
prepared my parts of this Form I-356 for me based only upon information I provided or authorized.

Form I-356 09/26/18

,

Page 9 of 13

Part 7. Alien's (or Alien Executor's) Contact Information, Certification, and Signature (continued)
Alien's (or the Alien's Executor's) Contact Information
3.

Daytime Telephone Number

5.

Email Address (if any)

4.

Mobile Telephone Number (if any)

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Federal Agency Disclosure and Authorizations
I

,

authorize the Social Security Administration (SSA) to verify my/the alien's Social Security number (to match my name, Social
Security number, and date of birth with information in SSA records and provide the results of the match) to USCIS. I (the alien/the
alien's executor) authorize SSA to provide explanatory information to USCIS as necessary.
I

,

authorize the SSA, U.S. Department of Agriculture (USDA), and U.S. Department of Health and Human Services (HHS), the
Department of Housing and Urban Development (HUD), and any other government agency that has received and/or adjudicated a
request for a public benefit, as defined in 8 CFR 212.21(b) submitted by me/the alien or on my/the alien's behalf, and/or granted one or
more public benefits to me/the alien to disclose to USCIS that I (the alien/alien's executor) have applied for, received, or have been
certified to receive, a public benefit from such agency, including the type and amount of benefit(s), date(s) of receipt and any other
relevant information provided to the agency for the purpose of obtaining such public benefit, to the extent permitted by law. I (the
alien/the alien's executor) also authorize SSA, USDA, HHS, HUD, and any other government agency to provide any additional data
and information to USCIS, to the extent permitted by law.
I

,

authorize custodians of records and other sources of information pertaining to my/the alien's request for or receipt of public benefits to
release information regarding my/the alien's request for and/or receipt of public benefits, upon the request of the investigator, special
agent, or other duly accredited representative of any federal agency authorized above, regardless of any previous agreement to the
contrary.
I

,

understand that the information released by records custodians and sources of information is for official use by the federal
government, that the government will use it only to review my/the alien's eligibility for immigration benefits and to enforce
immigration laws, and that the government may disclose the information only as authorized by law.

Alien's (or Alien's Executor's) Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine whether the bond should be cancelled.
I furthermore authorize release of information contained in this form, in supporting documents, and in my/the alien's USCIS records,
to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

Alien's (or Alien's Executor's) Signature
6.

Alien's (or Alien's Executor's) Signature

Date of Signature (mm/dd/yyyy)

NOTE to Aliens (or Alien's Executor): If you do not completely fill out your parts of Form I-356 or fail to submit required
documents listed in the Instructions, USCIS may deny the request to cancel the bond.
Form I-356 09/26/18

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Part 8. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

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Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Country

Postal Code

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification

I certify, under penalty of perjury, that:
I am fluent in English and

, which is the same language provided in Part 7.,

Item B. in Item Number 1., and I have read to this alien or the alien's executor in the identified language every question and
instruction on the alien's parts of Form I-356 and his or her answer to every question. The alien or the alien's executor informed me
that he or she understands every instruction, question, and answer in the alien's parts of Form I-356, including the Alien (or the
Alien's Executor's) Certification, and has verified the accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature

Form I-356 09/26/18

Date of Signature (mm/dd/yyyy)

Page 11 of 13

Part 9. Contact Information, Certification, and Signature of the Person Preparing the Alien's Parts of
Form I-356, if Other Than the Alien (or the Alien's Executor)
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Given Name (First Name)

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Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared the alien's part of this form on behalf of the alien or
the alien's executor and with the alien's or the alien's executor's consent.

B.

I am an attorney or accredited representative and my representation of the alien or the alien's executor in this case
extends
does not extend beyond the preparation of this form.

NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, with this Form.

Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared the alien's parts of this form at the request of the alien or the alien's
executor. The alien or the alien's executor then reviewed these completed parts of this form and informed me that he or she
understands all of the information contained in, and submitted with, the alien's parts of Form I-356, including the Alien's (or the
Alien's Executor's) Certification, and that all of this information is complete, true, and correct. I completed the alien's parts of the
form based only on information that the alien or the alien's executor provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

Form I-356 09/26/18

Date of Signature (mm/dd/yyyy)

Page 12 of 13

Part 10. Additional Information
If you need extra space to provide any additional information within this request, use the space below. If you need more space than
what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of paper. Please
type or print the alien's name and A-Number (if any), the obligor's name, and bond receipt number, at the top of each additional sheet;
indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A.

A.

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

D.

5.

A.

D.

6.

A.

Middle Name

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Page Number

D.

4.

Given Name (First Name)

D.

7.

A.

D.

Form I-356 09/26/18

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