Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 3
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8Periods of Unlawful Presence
Part 2. Reasons You Are Filing Form I-212
(continued)
5.b.
From (mm/dd/yyyy)
2.a. Date you were removed from the United States
5.c.
To (mm/dd/yyyy)
(mm/dd/yyyy)
6.a.
Date you departed the United States after your period of
2.b.
Location from where you were removed
unlawful presence (mm/dd/yyyy)
City or Town
6.b.
Location where you departed the United States after your
period of unlawful presence
State
City or Town
State
Removal as a Deportable Alien (INA section
212(a)(9)(A)(ii))
3.a.
I have been removed as a deportable alien under INA
6.c.
Location where you reentered or attempted to reenter the
section 240 or any other provision of the law, or I
United States
departed the United States while an order of removal
City or Town
was outstanding.
Yes
No
I have only been removed once and my removal was
3.b.
State
less than 10 years ago.
I have been removed at least two or more times, and
3.c.
6.d. Date you attempted to unlawfully enter or reenter the
my last removal was less than 20 years ago.
United States after period of unlawful presence
(mm/dd/yyyy)
3.d.
I have been convicted of an aggravated felony in the
United States or abroad, before or after my removal
from the United States. Provide information on your
Entry After Removal (INA section
aggravated felony convictions in Part 8. Additional
212(a)(9)(C)(i)(II))
Information and include the required evidence.
7.a
I entered or attempted to enter the United States without
4.a. Date you were excluded, deported, or removed from the
being admitted or paroled after having been excluded,
United States (mm/dd/yyyy)
deported, or removed.
Yes
No
4.b.
Location from where you were removed
NOTE: If you answered “Yes” to Item Number 7.a.,
City or Town
list all the dates when you were excluded, deported, or
removed from the United States. If you need extra space
to complete this section, use the space provided in Part 8.
State
Additional Information.
7.b.
Date you were excluded, deported, or removed from the
United States (mm/dd/yyyy)
Entry After Unlawful Presence in the Aggregate of
1 Year (INA section 212(a)(9)(C)(i)(I))
8.a.
Location where you reentered or attempted to reenter the
5.a.
I entered or attempted to enter the United States without
United States after your exclusion, deportation, or removal
being admitted or paroled, after having been unlawfully
City or Town
present in the United States on or after April 1, 1997, for
a period of more than one year, in the aggregate.
State
Yes
No
NOTE: If you answered "Yes" to Item Number 5.a., list
8.b.
Date you entered or attempted to reenter the United States
all the time periods during which you were unlawfully
after exclusion, deportation, or removal (mm/dd/yyyy)
present in the United States (including any periods in
which you overstayed your lawful status). Begin with
your most recent period of unlawful presence. Also attach
evidence demonstrating that you have remained outside
the United States for 10 years since your last departure.
Form I-212 12/23/16 N
Page 3 of 8
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