Form I-246 - Application For A Stay Of Deportation Or Removal Page 3

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DEPARTMENT OF HOMELAND SECURITY

OMB No. 1653-0021

Expires: 07/31/2019

U.S. Immigration and Customs Enforcement

APPLICATION FOR A STAY OF DEPORTATION OR REMOVAL

Action Block - For ICE Use Only

Fee/Date Stamp

GRANTED

One Year

Six Months

Three Months

Other:

DENIED

Denial letter attached.

REJECTED

Incorrect Fee

Application was not submitted in person

Other:

Additional information attached.

Date:

Decision made by:

(Printed Name/Title)

Deciding Official Signature

Office:

(Sign in ink):

A-File Number:

Date:

If you are currently detained by ICE, provide the name of the detention facility:

Last Name:

First Name:

Middle Name:

Address (Number and Street):

Country of Citizenship:

Passport No:

Expiration Date:

Apartment Number:

Length of stay requested:

six months

three months

other:

one year

Town/City:

State:

Zip Code:

Arrested by police or other law enforcement agency (other than for

immigration reasons)

Telephone Number:

Cell Telephone Number:

Yes - Documents attached

REASON(S) FOR REQUESTING A STAY OF DEPORTATION OR REMOVAL:

EVIDENCE SUBMITTED (attached):

Medical

Brief

Other (specify):

I certify under penalty of perjury that the information provided and contained herein is true and correct to the best of my knowledge and belief:

(Printed Name)

(Signature) (Sign in ink)

INFORMATION IF FORM PREPARED BY OTHER THAN APPLICANT:

I declare under penalty of law that this document was prepared by me at the request of the applicant and is based on all information of which I have

knowledge. I understand that providing false information on behalf of the applicant could result in criminal prosecution and, upon conviction, a fine or

imprisonment or both.

(Printed Name)

(Signature) (Sign in ink)

(Telephone Number)

(Street Address)

(City)

(State)

(Zip Code)

ICE Form I-246 (10/17)

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