Fill - Free fillable Form Eoir 42a (Visa Pro) PDF form

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. 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(a)(2) of the INA, or prior to committing a security or related offense

referred to in section 237(a)(4) of the INA;

-- you have at least seven (7)years continuous residence in the United States after having been

lawfully admitted in any status; 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 2014

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for

Certain Permanent Residents

III. 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 2014

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

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 infor-

mation. You will be given instructions on how to complete this requirement. You will be notified in writing of the loca-

tion 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 fur-

nish 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 2014

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

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 Department of Homeland Security (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 docu-

ments 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 docu-

ments 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.

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.

Form EOIR-42A

Revised July 2014

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for

Certain Permanent Residents

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 deter-

mined 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 20530.

Form EOIR-42A

Revised July 2014

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for

Certain Permanent Residents

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for

Certain Permanent Residents

Form EOIR-42A

Revised July 2014

PLEASE READ ADVICE AND INSTRUCTIONS

BEFORE FILLING IN FORM

PLEASE TYPE OR PRINT

Fee Stamp (Official Use Only)

PART 1 - INFORMATION ABOUT YOURSELF

1) My present true name is: (Last, First, Middle)

3) My name given at birth was: (Last, First, Middle)

5) Date of Birth: (Month, Day, Year)

10) Current Nationality and Citizenship:

6) Gender:

❏ Male ❏ Female

11) Social Security Number:

2) Alien Registration (or “A”) Number(s):

4) Birth Place:

(City and Country)

7) Height: 8) Hair Color: 9) Eye Color:

12) Home Phone Number:

( )

13) Work Phone Number:

( )

14) I currently reside at:

Apt. number and/or in care of

Number and Street

City or Town State Zip Code

15) I have been known by these additional name(s):

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:

(Month, Day, Year)

Resided To:

(Month, Day, Year)

PRESENT

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)

PART 2 - INFORMATION ABOUT THIS APPLICATION

Please continue answers on a separate sheet as needed.

(1)

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) .

(City and State)

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 .

❏ I entered using a visa which is valid until .

❏ was not inspected and admitted.

❏ I entered without documents. Explain: .

❏ I entered without inspection. Explain: .

❏ Other. Explain: .

22) I applied on for additional time to stay and it was ❏ granted on

and valid until , or

❏ denied on .

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:

❏

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

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

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

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

Purpose of Travel

Manner of Return

Purpose of Travel

Manner of Return

Destination

Inspected and Admitted?

❏ Yes ❏ No

Destination

Departure Date (Month, Day, Year)

Return Date (Month, Day, Year)

Departure Date (Month, Day, Year)

Return Date (Month, Day, Year)

Inspected and Admitted?

❏ Yes ❏ No

24) Have you ever departed the United States: 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)

31) Place and date of birth of my spouse: (City & Country; Month, Day, Year)

30) My spouse currently resides at:

Apt. number and/or in care of

Number and Street

City or Town State/Country Zip Code

32) My spouse is a citizen of: (Country)

34) My spouse ❏ - is ❏ - 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)

(Month, Day, Year)

(Specify Type of Visa)

(Month, Day, Year)

❏

Form EOIR-42A

Revised July 2014

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.)

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

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.)

PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS

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

Jointly Owned With Spouse

Cash, Stocks, and Bonds................................ $ Cash, Stocks, and Bonds................................ $

Real Estate...................................................... $ Real Estate...................................................... $

Auto (dollar value minus amount owed)....... $ Auto (dollar value minus amount owed)........ $

Other (describe on line below)....................... $ Other (describe on line below)....................... $

TOTAL $ TOTAL $

Please continue answers on a separate sheet as needed.

(3)

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

Date marriage began:

Date marriage ended:

Place marriage ended:

(City and Country)

Description or manner of how marriage was

terminated or ended:

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

Date marriage began:

Date marriage ended:

Place marriage ended:

(City and Country)

Description or manner of how marriage was

terminated or ended:

Full Name and Address of Employer

Earnings Per Week

(Approximate)

Type of Work

Performed

Employed From:

(Month, Day, Year)

Employed To:

(Month, Day, Year)

PRESENT

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:

Form EOIR-42A

Revised July 2014

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:

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

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:

Name of Child: (Last, First, Middle)

Child’s Alien Registration Number:

Citizen of What Country:

Birth Date:

(Month, Day, Year)

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:

Now Residing At: (City and Country)

Birth Date: (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

Name: (Last, First, Middle)

Alien Registration Number:

Citizen of What Country:

Birth Date:

(Month, Day, Year)

Relationship to Me:

Birth Date:

(City and Country)

A#:

Complete Address of Current Residence, if Living:

Immigration Status

of Listed Relative

A#:

Complete Address of Current Residence, if Living:

Please continue answers on a separate sheet as needed.

(4)

If you answered “No” to any of the

responses, please explain:

Form EOIR-42A

Revised July 2014

PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6)

Please continue answers on a separate sheet as needed.

(5)

50) Have you ever served in the Armed Forces of the United States? ❏ - Yes ❏ - No. If “Yes” please state branch (Army, Navy, etc.) and

service number:

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

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.

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,

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.)

48) I ❏ - have ❏ - have not submitted address reports as required by section 265 of the Immigration and Nationality Act.

52) Have you ever deserted from the military or naval forces of the United States while the United States was at war? ❏ Yes ❏ No

53) If male, did you register under the Military Selective Service Act or any applicable previous Selective Service (Draft) Laws? ❏ Yes ❏ No

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

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 16

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

Member From:

(Month, Day, Year)

Member To:

(Month, Day, Year)

Form EOIR-42A

Revised July 2014

PART 7 - MISCELLANEOUS INFORMATION (Continued)

Please continue answers on a separate sheet as needed.

(6)

56) Have you ever:

❏ Ye s ❏ No been ordered deported, excluded, or removed?

❏ Ye s ❏ 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)?

❏ Ye s ❏ No failed to appear for deportation or removal?

57) Have you ever been:

❏ Yes ❏ No a habitual drunkard?

❏ Yes ❏ No one whose income is derived principally from illegal gambling?

❏ Yes ❏ No one who has given false testimony for the purpose of obtaining immigration benefits?

❏ Yes ❏ No one who has engaged in prostitution or unlawful commercialized vice?

❏ Ye s ❏ No involved in a serious criminal offense and asserted immunity from prosecution?

❏ Ye s ❏ No a polygamist?

❏ Ye s ❏ No one who brought in or attempted to bring in another to the United States illegally?

❏ Ye s ❏ 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)?

❏ Ye s ❏ No inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?

❏ Ye s ❏ 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?

❏ Ye s ❏ 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) 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.)

Form EOIR-42A

Revised July 2014

PART 8 - SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT

Please continue answers on a separate sheet as needed.

(7)

(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 applica-

tion was read to the applicant in a language the applicant speaks fluently for verification before he or she signed the applica-

tion 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.

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)

I hereby certify that a copy of the foregoing Form EOIR-42A was:

❏ - delivered in person ❏ - mailed first class, postage prepaid

on 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)

Signature of Preparer: Print Name: Date:

Daytime Telephone #:

( )

Address of Preparer: (Number and Street, City, State, Zip Code)

PART 10 - PROOF OF SERVICE

PART 9 - SIGNATURE

Form EOIR-42A

Revised July 2014

(Month, Day, Year)

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Fillable Form Eoir 42a (Visa Pro)

Fill Online, Printable, Fillable, Blank Form Eoir 42a (Visa Pro) Form

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