Record of Abandonment of
Lawful Permanent Resident Status
USCIS
Form I-407
Department of Homeland Security
OMB No. 1615-0130
U.S. Citizenship and Immigration Services
Expires 03/31/2019
10.
State the reasons for abandoning lawful permanent
Part 1. Information About the Alien
resident status.
1.
Alien Registration Number (A-Number)
A-
►
2.
USCIS Online Account Number (if any)
►
Your Full Legal Name
Documents Surrendered and Location of
Submission
3.a. Family Name
(Last Name)
11.a.
Form I-551 (Permanent Resident Card)
Yes
No
3.b. Given Name
(First Name)
11.b.
If the Form I-551 is not surrendered, select the reason why.
3.c. Middle Name
Lost
Stolen
Mutilated
Other
11.c.
List other documents surrendered (if any).
Other Information
4.
Date of Birth
(mm/dd/yyyy)
5.
Country of Birth
12.a.
I am submitting Form I-407 outside of the United
States in-person.
6.
Country of Citizenship or Nationality
12.b.
I am submitting Form I-407 outside of the United
States by mail.
12.c.
I am submitting Form I-407 at a U.S. Port of Entry.
7.
Date of Last Departure from the United States
(mm/dd/yyyy)
Certification
I knowingly, willingly, and affirmatively declare that I have no
Mailing Address Abroad
intention of residing permanently in the United States, and that
8.a. In Care Of Name (if applicable)
by signing and submitting this form, I intend to record the fact
that I have knowingly and willingly abandoned my lawful
permanent resident status in the United States. I have been
8.b.
Street Number
informed of, and I understand my rights to a hearing before an
and Name
immigration judge about whether I have abandoned my lawful
permanent resident status in the United States. By signing and
8.c.
Apt.
Ste.
Flr.
submitting this form, I knowingly, willingly, and affirmatively
waive my rights to such a hearing.
8.d. City or Town
13.a. Signature of Alien (sign in ink)
8.e. Province or State
13.b. Date of Signature (mm/dd/yyyy)
8.f.
Postal Code
NOTE: Signing this form is voluntary. U.S. law does not
8.g.
Country
require you to complete, sign, or submit this form. You may
request a hearing before an immigration judge if you disagree
with a DHS allegation that you have abandoned your lawful
9.
E-mail Address (if any)
permanent residence.
Form I-407 03/31/17 Y
Page 1 of 2