Form EOIR-42a

OMB#ll25-0001
U.S. Department of Justice
Executive Office for Immigration Review

Application for Cancellation of Removal for
Certain Permanent Residents
ADVICE TO APPLICANT

PLEASE READ CAREFULLY. FEES WILL NOT BE RETURNED.

I.

Permanent Resident Aliens Eligible for Cancellation of Removal: You may be eligible to have your
removal cancelled under section 240A(a) of the Immigration and Nationality Act (INA). To qualify for this
benefit, you must establish in a hearing before an Immigration Judge that:
A.

You have been a permanent resident for at least five (5) years;

B.

You have at least seven (7) years continuous residence in the United States after having been
lawfully admitted in any status prior to service of the Notice to Appear, or prior to committing
a criminal or related offense referred to in sections 212(a)(2) and 237(1)(2) of the INA, or prior to
committing a security or related offense referred to in section 237(1)(4) of the INA; and

C.

You have not been convicted of an aggravated felony.

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 residence 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.
II.

Permanent Resident Aliens NOT Eligible for Cancellation of Removal: You are not eligible to have
your removal cancelled under section 240A(a) of the INA 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
section 101(a)(15)(J) of the INA in order to receive a 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
section 101(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 an alien who is either inadmissible under section 212(a)(3) of the INA or deportable under
section 237(a)(4) of the INA;

E.

Are an alien who ordered, incited, assisted, or otherwise participated in the persecution of an
individual because of the individual's race, religion, nationality, membership in a particular social
group, or political opinion; or

F.

Are an alien who was previously granted relief under section 212(c) of the INA, or section 244(a) of
the INA as such sections were in effect prior to the enactment of the Illegal Immigration Reform and
Immigrant Responsibility Act of 1996, or whose removal has previously been cancelled under section
240A of the INA.

Form EOIR-42A
Revised July 2016

OMB#ll25-0001
U.S. Department of Justice
Executive Office for Immigration Review

III.

Application for Cancellation of Removal for
Certain Permanent Residents

How Permanent Resident Aliens Can Apply for Cancellation of Removal
If you believe that you have met all the requirements for cancellation of removal, you must answer all the
questions on the attached Form EOIR-42A 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 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 7 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-42A
Revised July 2016

OMB#ll25-0001
U.S. Department of Justice
Executive Office for Immigration Review

Application for Cancellation of Removal for
Certain Permanent Residents
INSTRUCTIONS

1. PREPARATION OF APPLICATION.
To apply for cancellation of removal as a permanent resident alien under section 240A(a) of the Immigration and
Nationality Act (INA), you must fully and accurately answer all questions on the attached Form EOIR-42A. You must
also comply with all of the instructions on this form. These instructions have the force of law. A separate application
must be prepared and executed for each person applying for cancellation of removal. 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 the additional sheet, write your alien registration number, print your name, and sign,
date, and securely attach each additional sheet to the Form EOIR-42A.

2. BURDEN OF PROOF.
The burden of proof is on you to prove that you meet all of the statutory requirements for cancellation of removal for
certain permanent resident aliens under section 240A(a) 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 relief
(see "SUPPORTING DOCUMENTS" below).

3. SUPPORTING DOCUMENTS.
You should submit with your application copies of any documents which the Department of Homeland Security (DHS),
formerly the Immigration and Naturalization Service, issued to you. You should also submit all documents related to your
criminal history, including all conviction records. The Immigration Judge may require you to submit additional records
relating to your request for cancellation of removal.
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.

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 appointment 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.

Form EOIR-42A
Revised July 2016

OMB#ll25-0001
U.S. Department of Justice
Executive Office for Immigration Review

Application for Cancellation of Removal for
Certain Permanent Residents

6. FEES.
Before you file your Form EOIR-42A with the Immigration Court, you must pay the required $100 filing fee and the
biometrics fee to the 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-42A. 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-42A without fee (fee
waiver).

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 made 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.

7. SERVING & 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-42A, Application for Cancellation of Removal, with all supporting documents and additional sheets;
- a copy of the USCIS ASC notice of fee receipt and biometrics appointment instructions; and
- the original Biographical Information Form G-325A.
You must file the following documents with the appropriate Immigration Court:
- the original Form EOIR-42A with all supporting documents and additional sheets;
- a copy of the USCIS ASC notice of fee receipt and biometrics appointment instructions;
- a copy of the Biographical Information Form G-325A; and
- a completed certificate showing service of these documents (See Part 10 of the Application on page 7)
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-42A
Revised July 2016

OMB#ll25-0001
U.S. Department of Justice
Executive Office for Immigration Review

Application for Cancellation of Removal for
Certain Permanent Residents

8. PENALTIES.
You must answer all questions on Form EOIR-42A 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 docu-ments
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 removal should be cancelled and whether you should be permitted to
retain your 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
appli-cation, 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
support-ing 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 U.S.C. 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.

9. 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
currently valid OMB control number. We try to create forms and instructions that are accurate, can easily be under-stood,
and which impose the least possible burden on you to provide us with information. Often, this process 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, 50 minutes, (2) completing the form, 2 hours, and (3) assembling and filing the form, 3
hours, for an average of 5 hours, 50 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 bur-den, 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.

Form EOIR-42A
Revised July 2016

OMB#ll25-0001
U.S. Department of Justice
Executive Office for Immigration Review

Application for Cancellation of Removal for
Certain Permanent Residents

PLEASE READ ADVICE AND INSTRUCTIONS
BEFORE FILLING IN FORM

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)

6) Gender:
❏ Male

10) Current Nationality and Citizenship:

11) Social Security Number:

❏ Female

14) I currently reside at:

7) Height:

8) Hair Color:

12) Home Phone Number:

(

)

9) Eye Color:

13) 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 7 years.)
Street and Number - Apt. or Room # - City or Town - State - Zip Code

Resided From:

Resided To:

(Month, Day, Year)

(Month, Day, Year)

PRESENT

PART 2 - INFORMATION ABOUT THIS APPLICATION
17) I, the undersigned, hereby request that my removal be cancelled under the provisions of section 240A(a) of the Immigration and
Nationality Act (INA). I believe that I am eligible for this relief because I have been a lawful permanent resident alien for 5 or more
years, have 7 years of continuous residence in the United States, and have not been convicted of an aggravated felony. I was
admitted as or adjusted to the status of an alien lawfully admitted for permanent residence on
(Date)

at

.
(Place)

Please continue answers on a separate sheet as needed.
(1)

Form EOIR-42A
Revised July 2016

PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES
18) My first arrival into the United States was under the name of: (Last, First, Middle)

19) My first arrival to the United States was on: (Month, Day, Year)

20) Place or port of first arrival: (Place or Port, City, and State)
21) I:

❏

❏

was inspected and admitted.
❏ I entered using my Lawful Permanent Resident card which is valid until
Category on Lawful Permanent Resident card_____________________
❏ I entered using a
visa which is valid until
(Specify Type of Visa)

❏

.

(Month, Day, Year)

was not inspected and admitted.
❏ I entered without documents. Explain:

❏

.

(Month, Day, Year)

.

I entered without inspection. Explain:

.

Other. Explain:

22) I applied on

.
for additional time to stay and it was

(Month, Day, Year)

and valid until

, or ❏ denied on

(Month, Day, Year)

❏

granted 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 this box: ❏
1

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?

Port of Departure (Place or Port, City and State)

Departure Date (Month, Day, Year)

Purpose of Travel

Yes
Destination

Port of Return (Place or Port, City and State)

Return Date (Month, Day, Year)

Manner of Return

Inspected and Admitted?

❏

2

24) Have you ever departed the United States:

❏

❏ Yes ❏

No

No

a) under an order of deportation, exclusion, or removal?......................................❏ Yes

❏ No
b) pursuant to a grant of voluntary departure?...................................................... ❏ Yes ❏ No

PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued on page 3)
25) I am not married:
I am married:

❏
❏

26) If married, the name of my spouse is: (Last, First, Middle)

27) My spouse’s name before marriage was:

28) The marriage took place in: (City and Country)

29) Date of marriage: (Month, Day, Year)

30) My spouse currently resides at:

31) Place and date of birth of my spouse: (City & Country; 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:
He/she arrived in the United States at: (Place or Port, City and State)

.

He/she arrived in the United States on: (Month, Day, Year)

.

His/her alien registration number(s) is: A#
He/she was naturalized on: (Month, Day, Year)
34) My spouse

❏

- is

❏

.
at

.

(City and State)

- 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)

$
$
$
Please continue answers on a separate sheet as needed.
(2)

Form EOIR-42A
Revised July 2016

PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued)
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)

Name of prior spouse: (Last, First, Middle)

Date marriage began:
Date marriage ended:

Place marriage ended:

Date marriage began:
Date marriage ended:

Place marriage ended:

(City and Country)

(City and Country)

Description or manner of how marriage was
terminated or ended:

Description or manner of how marriage was
terminated or ended:

36) 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
37) Since my arrival 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

$
$
$
38) If self-employed, describe the nature of the business, the name of the business, its address, and net income derived therefrom:

39) 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...................................................... $
Auto (dollar value minus amount owed) ....... $
Other (describe on line below)....................... $
TOTAL $

Jointly Owned With Spouse
Cash, Stocks, and Bonds................................ $
Real Estate...................................................... $
Auto (dollar value minus amount owed)........ $
Other (describe on line below)....................... $
TOTAL $

40) I ❏ - have ❏ - have not received public or private relief or assistance (e.g., Welfare, Unemployment Benefits, Medicaid, TANF, AFDC, 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
total amount received during this time:

41) Please list each of the years in which you have filed an income tax return with the Internal Revenue Service:

Please continue answers on a separate sheet as needed.
(3)

Form EOIR-42A
Revised July 2016

PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued on page 5)
42) I have
(Number of) children. Please list information for each child below, include assets and earnings information for
children over the age of 16 who have separate incomes:
Name of Child: (Last, First, Middle)
Child’s Alien Registration Number:

Citizen of What Country:
Birth Date: (Month, Day, Year)

Now Residing At: (City and Country)
Birth Place: (City and Country)

A#:
Estimated Total of Assets: $

Estimated Average Weekly Earnings: $

A#:
Estimated Total of Assets: $

Estimated Average Weekly Earnings: $

A#:
Estimated Total of Assets: $

Estimated Average Weekly Earnings: $

Immigration Status
of Child

43) If your application is denied, would your spouse and all of your children accompany you to your:
Country of Birth -

❏ Yes ❏ No

Country of Nationality -

❏ Yes ❏ No

Country of Last Residence -

❏ Yes ❏ No

If you answered “No” to any of the
responses, please explain:

44) 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:

45) 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)

Relationship to Me: Birth
Place: (City and Country)

Immigration Status
of Listed Relative

A#:
Complete Address of Current Residence, if Living:

A#:
Complete Address of Current Residence, if Living:

Please continue answers on a separate sheet as needed.
(4)

Form EOIR-42A
Revised July 2016

PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6)
46) I

❏ - have ❏ - have not entered the United States as a crewman after June 30, 1964.

47) 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.
49) I ❏ - have ❏ - have never (either in the United States or in any foreign country) been arrested, summoned into court as a defendant, convicted, fined,

48) I

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, date of conviction, any penalty imposed, any sentence imposed, and the time actually served. You are
required to submit documentation of any such occurrences.)

50) 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)

.

51) 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
52) Have you ever deserted from the military or naval forces of the United States while the United States was at war?
53) If male, did you register under the Military Selective Service Act or any applicable previous Selective Service (Draft) Laws?
If “Yes,” please give date, Selective Service number, local draft board number, and your last draft classification:

54) Were you ever exempted from service because of conscientious objection, alienage, or any other reason?

❏ Yes ❏ No
❏ Yes ❏ No

❏ Yes ❏

No

55) 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.
(5)

Member From:

(Month, Day, Year)

Member To:

(Month, Day, Year)

Form EOIR-42A
Revised July 2016

PART 7 - MISCELLANEOUS INFORMATION (Continued)
56) Have you ever:

❏
❏

Yes

No

been ordered deported, excluded, or removed?

Yes

❏
❏

No

overstayed a grant of voluntary departure from an Immigration Judge or the Department of Homeland Security
(DHS), formerly the Immigration and Naturalization Service (INS)?

❏

Yes

❏

No

failed to appear for deportation or removal?

57) 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 brought in or attempted to bring in another to the United States illegally?

No

a trafficker of a controlled substance, or a knowing assister, abettor, conspirator, or colluder with others in any such controlled
substance offense (not including a single offense of simple possession of 30 grams or less of marijuana)?

❏
❏

Yes
Yes

❏
❏

No

inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?

No

one who has ordered, incited, assisted, or otherwise participated in the persecution of an individual on account of his
or her race, religion, nationality, membership in a particular social group, or political opinion?

❏

Yes

❏

No

a person previously granted relief under sections 212(c) or 244(a) of the INA or whose removal has previously been
cancelled under section 240A of the INA?

If you answered “Yes” to any of the above questions, explain:

58) Education: Name of School, Type of School, Degree Earned / Date (if any), Location (City/Country), Attended From (MM/YY) To (MM/YY)

59) 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.
(6)

Form EOIR-42A
Revised July 2016

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-42A 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-42A was:
on
at

(Month, Day, Year)

❏

- delivered in person

❏

- mailed first class, postage prepaid

to the Assistant Chief Counsel for the DHS (U.S. Immigration and Customs Enforcement-ICE)

(Number and Street, City, State, Zip Code)

Signature of Applicant (or Attorney or Representative)

Please continue answers on a separate sheet as needed.
(7)

Form EOIR-42A
Revised July 2016