Fee Stam
SUBMIT IN DUPLICATE
File No.
Date
1. Name (Family Name in CAPITAL letters, First, Middle)
2. Present Address
A
t. No.
Number and Street
State
Town or Cit
Zi
Code
3. Countr
of Citizenshi
4. Date to which passport is valid (Attach passport)
5. Countr
to which de
ortation or removal has been ordered 6. Date to which sta
of de
ortation or removal is re
uested
7. Reasons for requesting stay of deportation or removal
8. I certif
that the statements I have made in this a
lication are true and correct to the best of m
knowled
e and belief.
(Location) (Date)(Signature)
Si
nature
Printed Name
Date
APPLICANT: DO NOT WRITE BELOW THIS LINE
Denied Granted Stay
at
Place Where Granted
Date
By
(Date)(Title)(Signature)
Form I-246
Rev. 09/19/00
Y
U.S. De
artment of Justice
Immi
ration and Naturalization Service
OMB APPROVAL NO. 1115-0055
A
lication for Sta
of De
ortation or Removal
ead instructions on reverse before filling out application
9. Si
nature of
erson
re
arin
form, if other than a
licant.
I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have knowledge. Failure by
a preparer to complete this block may result in criminal prosecution and, upon conviction, a fine or imprisonment.
