Form I-589 - Application For Asylum And For Withholding Of Removal
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12Department of Homeland Security
OMB No. 1615-0067; Expires 05/31/2019
U.S. Citizenship and Immigration Services
I-589, Application for Asylum
U.S. Department of Justice
and for Withholding of Removal
Executive Office for Immigration Review
START HERE - Type or print in black ink. See the instructions for information about eligibility and how to complete and file this
application. There is no filing fee for this application.
NOTE:
Check this box if you also want to apply for withholding of removal under the Convention Against Torture.
Part A.I. Information About You
1. Alien Registration Number(s) (A-Number) (if any) 2. U.S. Social Security Number (if any)
3. USCIS Online Account Number (if any)
4. Complete Last Name
5. First Name
6. Middle Name
7. What other names have you used (include maiden name and aliases)?
8. Residence in the U.S. (where you physically reside)
Street Number and Name
Apt. Number
City
State
Zip Code
Telephone Number
(
)
8)
9. Mailing Address in the U.S. (if different than the address in Item Number
In Care Of (if applicable):
Telephone Number
(
)
Apt. Number
Street Number and Name
City
State
Zip Code
11. Marital Status:
10. Gender:
Male
Female
Single
Married
Divorced
Widowed
12. Date of Birth (mm/dd/yyyy)
13. City and Country of Birth
14. Present Nationality (Citizenship)
15. Nationality at Birth
16. Race, Ethnic, or Tribal Group 17. Religion
18. Check the box, a through c, that applies:
a.
I have never been in Immigration Court proceedings.
b.
I am now in Immigration Court proceedings.
c.
I am not now in Immigration Court proceedings, but I have been in the past.
19. Complete 19 a through c.
a. When did you last leave your country? (mmm/dd/yyyy)
b. What is your current I-94 Number, if any?
c. List each entry into the U.S. beginning with your most recent entry. List date (mm/dd/yyyy), place, and your status for each entry.
(Attach additional sheets as needed.)
Date
Place
Status
Date Status Expires
Date
Place
Status
Date
Place
Status
20. What country issued your last passport or travel
22. Expiration Date
21. Passport Number
document?
(mm/dd/yyyy)
Travel Document Number
23. What is your native language (include dialect, if applicable)? 24. Are you fluent in English?
25. What other languages do you speak fluently?
Yes
No
For EOIR use only.
For
Action:
Decision:
Interview Date:
Approval Date:
USCIS
Asylum Officer ID No.:
Denial Date:
use only.
Referral Date:
Form I-589 (Rev. 05/16/17) N
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