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Item Number 4. Date of Birth. Enter the alien’s date of birth in month/day/year format mm/dd/yyyy.

Item Numbers 5. - 6. Country of Birth and Country of Citizenship or Nationality. Enter the name of the country of

the alien’s birth and the name of the country of the alien’s citizenship or nationality. The name of the country should be

the current name of the country.

Item Number 7. Date of Last Departure from the United States. Enter the date of last departure from the United

States.

Item Numbers 8.a. - 8.g. Mailing Address Abroad. Enter the alien’s mailing address abroad.

Item Number 9. E-mail Address (if any). Provide an E-mail address where the alien can be reached.

Item Number 10. Reasons for Abandonment. Enter the reasons for abandoning lawful permanent resident status.

Item Numbers 11.a. - 12.c. Documents Surrendered and Location of Submission. Select the corresponding boxes of

documents surrendered, list other documents surrendered, and select the corresponding boxes for location of submission.

Item Number 11.b. If selected, provide a detailed written statement explaining why the document cannot be surrendered.

This statement should be signed under oath before a DHS or consular officer. If you cannot appear before a DHS or

consular officer, then you must include in the statement, “I certify under penalty of perjury under United States law that

this statement is true and correct.”

Item Numbers 13.a. - 13.c. Certification. The permanent resident alien, or if 17 years of age or younger, his or her

parents, custodial parents, or legal guardians, must sign Form I-407 before it is accepted by DHS. If the lawful permanent

resident is a minor 17 years of age or younger, then each legal parent, custodial parents, or duly appointed legal guardian

must sign Form I-407 and consent to the submission of Form I-407. If the minor has only one legal parent, the sole legal

parent can sign Form I-407, but must submit proof showing that any other parent has died, has had his or her parental

rights terminated according to the law, or that the parent who is signing Form I-407 has sole legal custody of the minor.

A guardian should submit letters of guardianship or other proof of the authority to sign for the minor lawful permanent

resident alien.

Item Numbers 14.a. - 14.d. Parents, Custodial Parents, or Legal Guardian Name, Signature, and Date, (if

applicable). The parents, custodial parents, or legal guardian must sign and print their name and date in this section if they

are consenting to Form I-407 being submitted for the minor (17 years of age or younger) for whom they are responsible.

They must also submit evidence to establish sole parental or custodial responsibility, if applicable.

Lawful permanent residents submitting Form I-407 by mail should carefully read the following section of the instructions

regarding the rights of lawful permanent residents. If Form I-407 is completed in person, then before asking the

individual to sign Form I-407, the DHS officer or the DOS consular officer must explain that:

By signing Form I-407, the alien waives the right to a hearing before an immigration judge who would decide whether

the alien lost his/her legal permanent resident status due to abandonment. If the alien chooses a hearing before an

immigration judge instead, the alien would have the right:

1. To be represented at no expense to the U.S. Government by an attorney or accredited representative;

2. To challenge any evidence that DHS may present against the alien;

3. To present evidence in the alien’s favor;

4. To require that DHS prove, by clear, unequivocal, and convincing evidence, that the alien has lost his or her

lawful permanent resident status through abandonment; and

5. To appeal a decision against the alien.

Form I-401 Instructions 03/31/17 Y

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Instructions For Form I-407 - Record Of Abandonment Of Lawful Permanent Resident Status Page 2