Form I-356 10/15/19
Page 3 of 14
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 1. Obligor and Agent/Co-Obligor Information (To Be Completed by the Obligor or Agent/Co-Obligor)
(continued)
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)
Choose the appropriate statement and sign.
I (Name of the Obligor)
acting on behalf of (Name of the Obligor)
executed on Form I-945 on behalf of (Name of the Alien)
A. The Alien Naturalized, Permanently Departed the United States, or Died
,, or I (Name of the Agent/Co-Obligor)
, request that the public charge bond
,
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
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.
Cancellation Following The Alien's 5th Anniversary of the Alien's Admission as a Lawful Permanent Resident
(Name of the Agent/Co-Obligor, if any)
acting on behalf of (Name of the Obligor)
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.
executed on Form I-945 on behalf of (Name of the Alien)
born on (Alien Date of Birth (mm/dd/yyyy))
1.
B.
I (Name of the Obligor)
,, or I (Name of the Agent/Co-Obligor)
, request that the public charge bond
,
, and residing at
(Address of the Alien) ,
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
acting on behalf of (Name of the Obligor)
executed on Form I-945 on behalf of (Name of the Alien)
born on (Alien Date of Birth (mm/dd/yyyy))
I (Name of the Obligor) ,, or I (Name of the Agent/Co-Obligor)
, request that the public charge bond
,
, and residing at
(Address of the Alien) ,
be cancelled and that (Name of the Obligor)
,
and (Name of Agent/Co-obligor, if any)