Form I-407 Record of Abandonment of Lawful Permanent Resident Statu

Record of Abandonment of
Lawful Permanent Resident Status

USCIS
Form 1-407

Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in black ink.
Part 1. Information About You

OMB No. 1615-0130
Expires 05/31/2021

Mailing Address Outside of the United States
9.a. In Care Of Name (if applicable)

1.a. Alien Registration Number (A-Number)
A-

9.b. Street Number and Name

1.b. Your Name Exactly As It Appears On Your Permanent
Resident Card
9.c.
2.

USCIS Online Account Number (if any)

Your Current Legal Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

Apt.

ri ste.

Flr.

9.d. City or Town

9.e. Province or State

9.f.

Postal Code

9.g. Country

3.c. Middle Name
10.

Email Address (if any)

Other Information
4.

Date of Birth (mm/dd/yyyy)

5.

Country of Birth

NOTE: If you are outside of the United States, we recommend
that you provide your email address so we can contact you if
needed.

6.

Country of Citizenship or Nationality

Mailing Address Outside of the United States
Written in the Language Where You Reside

7.

Date of Last Departure from the United States

11.a. In Care Of Name (if applicable)

(mm/dd/yyyy)
8.

State the reasons for abandoning lawful permanent
resident status.

11.b. Street Number and Name

11.c.

Apt.

Ste.

Flr.

11.d. City or Town

11.e. Province or State

11.f. Postal Code
11.g. Country

Form 1-407 05/16/19

Page 1 of 3

A-Number 0. A-

Part 1. Information About You (continued)

Documents Returned and Location of Submission
12.a. Permanent Resident Card

Yes

No

12.b. If you did not return your Permanent Resident Card,
select the reason why and select and complete the
certification statement.
Mutilated
Lost
Stolen
Other

ri

12.c.

I certify, under penalty of perjury under the laws of
the United States of America that I no longer possess
my Permanent Resident Card for the reasons stated in
this form, which I signed on (mm/dd/yyyy)

12.d. List other documents you returned (if any).

13.a.

I am submitting Form 1-407 outside of the United
States in-person.

13.b. H I am submitting Form 1-407 outside of the United
States by mail.
13.c.

I am submitting Form 1-407 at a U.S. Port of Entry.

13.d.

I am submitting Form 1-407 from inside the United
States to document that I abandoned my lawful
permanent resident (LPR) status in the past. I already
abandoned my prior LPR status by leaving the United
States intending to make my permanent home abroad.
I did not retain my LPR status. I have since returned
to the United States through a port of entry by being
admitted as a nonimmigrant or by being paroled.

Certification
I knowingly, willingly, and affirmatively declare that I currently
have no intention of residing permanently in the United States,
and that by signing and submitting this form, I intend to record
the fact that I have knowingly and willingly abandoned my LPR
status in the United States. I have reviewed the form and its
instructions, and I have been informed of and I understand my
rights to a hearing before an immigration judge about whether I
have abandoned my LPR status in the United States. By
signing and submitting this form, I knowingly, willingly, and
affirmatively waive my rights to such a hearing.

I knowingly, willingly, and affirmatively declare that I already
abandoned my prior lawful permanent resident (LPR) status by
leaving the United States intending to make my permanent
home abroad and I did not retain my LPR status. I have since
returned to the United States through a Port of Entry by being
admitted as a nonimmigrant or by being paroled. I declare that I
am submitting this Form 1-407 to document that I abandoned
my prior LPR status. I have reviewed the form and its
instructions, and I have been informed, and I understand, that
had I not previously abandoned my LPR status, that I would
have a right to seek a hearing before an immigration judge to
contest the abandonment of my LPR status. By signing and
submitting this form, I knowingly, willingly, and affirmatively
waive my rights, if any, to such a hearing.
AND/OR

Consent of Parents Custodial Parent, or Legal
Guardian to Submit Form I-407 for Incapacitated
Adult or Minors 14 Years of Age and Younger
(if applicable)
I confirm that I am the parent, custodial parent, or duly
appointed legal guardian for the individual identified in Part 1.
of this form. As the parent or legal guardian of this individual, I
consent to the alien minor's/incapacitated adult's submission of
this form.
14.a. Your Signature (or signature of the parent, custodial
parent, or legal guardian, if applicable)

4
14.b. Your Name (or name of parent, custodial parents, or legal
guardian, if applicable)

14.c. Date of Signature (mm/dd/yyyy)
NOTE: Signing this form is voluntary. U.S. law does not
require you to complete, sign, or submit this form. You may
request a hearing before an immigration judge if you disagree
with a Department of Homeland Security (DHS) allegation that
you have abandoned your lawful permanent residence.
If signed by a parent, custodial parent, or legal guardian, submit
evidence to show parental, custodial parental, or legal
guardianship responsibility of the minor or incapacitated adult.

OR

Form I-407 05/16/19

Page 2 of 3

A-Number

Part 2. Interpreter's Contact Information,
Certification, and Signature

A-

Interpreter's Signature
7.a. Interpreter's Signature

Provide the following information about the interpreter.

Interpreter's Full Name

7.b. Date of Signature (mm/dd/yyyy)

1.a. Interpreter's Family Name (Last Name)

Part 3. For Government Use Only
1.b. Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

Instructions to the U.S. govermnent official: Select Item
Number 1. if you interviewed the individual identified in Part
1. If you did not, select Item Number 2. Sign the form and
provide other information requested.
1.

I certify that I personally interviewed the individual
identified in Part 1., who has signed this Form 1-407,
and that I advised the individual of the hearing rights
specified in the Instructions. The individual stated
that he or she fully understands the effect of signing
this Form 1-407. I further certify that, if an interpreter
was used, I confirmed that the individual understood
the internreter.

2.

I certify that I reviewed this Form 1-407, which was
submitted by mail as indicated in Part 1. Item
Number 13.b. Based on the completed information,
signature, and any attached documentation, the
individual identified in Part 1. has declared that he or
she fully understands the effect of submitting this
Form 1-407.

(USPS ZIP Code Lookup)

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Fir.

3.e. City or Town
3.d. State

3.e. ZIP Code

3.f. Province
3.g. Postal Code
3.h. Country
3.

Interpreter's Contact Inforination
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

A copy of the signed Form 1-407 was provided to this
individual.
Yes
No

U.S. Government Official Iuformation
4.a. Name of U.S. Government Official

4.b. Signature of U.S. Government Official (sign in ink or use
signature stamp)

4.c. Title of U.S. Government Official

Interpreter Certification
I certify, under penalty of perjury, that:
I am fluent in English and
and I have read to this respondent in the identified language every
question and instruction on this form and his or her answer to
every question. The respondent informed me that he or she
understands every instruction, question, and answer on the form,
including the Certification and the Consent of Parent, Custodial
Parent, or Legal Guardian to Submit Form 1-407 for
Incapacitated Adult or Minors 14 Years of Age and Younger
(if applicable), and has verified the accuracy of every answer.
Form I-407 05/16/19

4.d. Name of DHS Component, if signed by a DHS Official

4.e. Date of Signature (mm/dd/yyyy)

Page 3 of 3