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. 1615-0141
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

(USPS ZIP Code Lookup)

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-356 09/26/18

ZIP Code

Page 1 of 14

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 14

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 ofthe 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) for more than 12 months
in the aggregate within any 36 month period (such that, for instance, receipt of two benefits in one month counts as
two months), 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) for more than 12 months in the aggregate within any 36 month period (such
that, for instance, receipt of two benefits in one month counts as two months), 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))
(Address of the Alien)

,

,
, and residing at
,

be cancelled and that (Name of the Obligor)
and (Name of Agent/Co-obligor, if any)

Form I-356 09/26/18

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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) for more than 12 months in the aggregate within any 36 month period (such that, for instance,
receipt of two benefits in one month counts as two months), 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.

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Street Number and Name

Apt. Ste. Flr.

City or Town

State

Physical Address

ZIP Code

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

Number

ZIP Code

Country

Part 4. Reason for Cancellation of the Bond
1.

I am requesting a cancellation because:

I became a U.S. Citizen (answer Item Number 2.)

I permanently departed the United States (answer Item Number 3.)

The alien is deceased and I am the alien's executor (answer Item Number 4.)

Five years have passed since I became a lawful permanent resident (answer Item Number 5.)

Answer the following questions below based on the reason for requesting a cancellation of the bond, and provide the requested
information. You should indicate whether any of the circumstances addressed in the questions have occurred since the date you
adjusted your status to that of a lawful permanent resident (for which a bond was posted on your behalf). If you are the Executor of the
deceased alien's estate, answer these questions on behalf of the deceased alien.

Became a U.S. Citizen
2.

Have you become a United States citizen?

Yes

No. (Go to Item Number 3.)

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

Certificate of Naturalization Number or Citizenship Certificate Number (if applicable)

B.

Date of Naturalization or Acquired Citizenship
(mm/dd/yyyy)

D.

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

Form I-356 09/26/18

C.

U.S. Passport Number (if applicable)

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Part 4. Reason for Cancellation of the Bond (continued)
Permanently Departed the United States
3.

Have you permanently departed the United States? Provided documentation as provided in the Instructions.
Yes, I departed and submitted Form I-407 to the U.S. Government from outside the United States to record the abandonment
of my lawful permanent residence.
Yes, I departed after I was granted voluntary departure (under INA 240B).

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Yes, I departed after I received a final order of removal, exclusion or deportation (self-removed).

Yes, I was physically removed from the United States after I received a final order of removal, exclusion or deportation.
No, I have not permanently departed. (Go to Item Number 4.)

If you answered “Yes,” please provide the following information (as applicable) in Items. A. - D.
A.

Date you left the United States
(mm/dd/yyyy)

C.

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

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.

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

Deceased
4.

B.

Place of Departure/Removal, Exclusion, or Disposition

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

Yes

No. (Go to Item Number 5.)

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.

Date of Death (mm/dd/yyyy)

B.

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

Information about the person completing Item Number 4. 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):
Full Name
Family Name (Last Name)

Given Name (First Name)

Middle Name

Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-356 09/26/18

Postal Code

ZIP Code

Country

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Part 4. Reason for Cancellation of the Bond (continued)
Mailing Address
In Care Of Name (if any)

Street Number and Name

City or Town

Province

Apt. Ste. Flr. Number

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State

Postal Code

Daytime Telephone Number

ZIP Code

Country

Email Address (if any)

Relationship to Deceased

Five Years after Becoming a Lawful Permanent Resident
5.

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

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)

Part 5. 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 or are currently certified
to receive in the future the following public benefits for more than 12 months in the aggregate within any 36 month period?
Yes

No

Yes, I have received, or I am currently certified to receive in the future the following benefits:
Any Federal, State, local or tribal cash assistance for income maintenance
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
General Assistance (GA)
Supplemental Nutrition Assistance Program (SNAP, formerly called "Food Stamps")
Section 8 Housing Assistance under the Housing Choice Voucher Program
Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation)
Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.
Federal-funded Medicaid
No, I have not received any public benefits.
No, I am not certified to receive in the future any of the above public benefits.
Form I-356 09/26/18

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Part 5. 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)) (continued)
2.

If you received any of the above public benefits, provide information about the receipt of public benefits in the space provided.
If you need additional space to complete any Item Number in this Part, use the space provided in Part 9. Additional
Information. Submit evidence as outlined in the instructions.
A.

Type of Public Benefit

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Agency That Granted The Benefit

Date you were Authorized to Start Receiving the Benefit or Date Your Coverage Starts (mm/dd/yyyy)

Date Benefit or Coverage Ended or Expires or Expected to Expire (mm/dd/yyyy)

B.

Type of Public Benefit

Agency That Granted The Benefit

Date you were Authorized to Start Receiving the Benefit or Date Your Coverage Starts (mm/dd/yyyy)

Date Benefit or Coverage Ended or Expires or Expected to Expire (mm/dd/yyyy)

C

Type of Public Benefit

Agency That Granted The Benefit

Date you were Authorized to Start Receiving the Benefit or Date Your Coverage Starts (mm/dd/yyyy)

Date Benefit or Coverage Ended or Expires or Expected to Expire (mm/dd/yyyy)

Public Benefit Exemptions
3.

If you answered “Yes” to Item Number 1., check any box that is applicable to you and provide the evidence listed in the Form
I-356 Instructions if any of the following apply to you.
I am enlisted in the Armed Forces, or am serving in active duty or in the Ready Reserve Component of the U.S. Armed
Forces.
I am the spouse or the child of an individual who is enlisted in the Armed Forces, or is serving in active duty or in the
Ready Reserve Component of the U.S. Armed Forces.
At the time I received the public benefits, I (or my spouse or parent)
was enlisted
in the Armed Forces, or was serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.

Form I-356 09/26/18

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Part 5. 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)) (continued)
At the time I received the public benefits, I was present in the United States in a status exempt from the public charge
ground of inadmissibility and I received the public benefits during that time.
At the time I received the public benefits, I was present in the United States after being granted a waiver from the public
charge ground of inadmissibility and received the public benefits during that time.
At the time I received the benefits, I was a child of U.S. citizens whose lawful admission for permanent residence and
subsequent residence in the legal and physical custody of my U.S. citizen parent would result in me automatically acquiring
U.S. citizenship upon meeting the eligibility under INA 320 or the child of U.S. citizens whose lawful admission for
permanent residence will result automatically in my acquisition of citizenship upon finalization of adoption (and I satisfied
the requirements applicable to adopted children under INA 101(b)(1)), in the United States by the U.S. citizen parent(s),
upon meeting the eligibility criteria under INA 320; or I was a child residing abroad who entered the United States with a
nonimmigrant visa to attend an N-600K, Application for Citizenship and Issuance of Certificate Under INA Section 322
interview.

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None of the above statements apply to me.
4.

Have you received federal-funded Medicaid in connection with any of the following (select all that apply): Submit evidence as
outlined in the Instructions.
An emergency medical condition.

For a service under the Individuals with Disabilities Education Act (IDEA).

Other school-based benefits or services available up to the oldest age eligible for secondary education under State law.
While you were under the age of 21.

While you were pregnant or during the 60-day period following the last day of pregnancy.
None of the above apply to me.
A.

Provide the applicable dates (mm/dd/yyyy)

Part 6. 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.

Form I-356 09/26/18

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Part 6. Alien's (or Alien Executor's) Contact Information, Certification, and Signature (continued)
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.

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, as applicable, 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, as applicable, 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, as applicable, 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
as applicable, 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.

Form I-356 09/26/18

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Part 6. Alien's (or Alien Executor's) Contact Information, Certification, and Signature (continued)
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.

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Part 7. 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)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr.

Number

City or Town

State

ZIP Code

Province

Postal Code

Country

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 6.,

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.

Form I-356 09/26/18

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Part 7. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Signature
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 8. 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)

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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)

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.

Form I-356 09/26/18

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Part 8. 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) (continued)
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.

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Preparer's Signature
8.

Preparer's Signature

Form I-356 09/26/18

Date of Signature (mm/dd/yyyy)

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Part 9. 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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