Form Eoir-42b - Application For Cancellation Of Removal And Adjustment Of Status For Certain Nonpermanent Residents Page 10

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PART 6 - INFORMATION ABOUT YOUR FAMILY

(Continued)

IF THIS APPLICATION IS BASED ON HARDSHIP TO A PARENT OR PARENTS, QUESTIONS 47-50 MUST BE ANSWERED.

47) If your parent is not a citizen of the United States, give the date and place of arrival in the United States including full details as to the date,

manner, and terms of admission into the United States:

48) My father

- is

- is not employed. If employed, please give salary and the name and address of the place(s) of employment.

Full Name and Address of Employer

Earnings Per Week

(Approximate)

49) My mother

- is

- is not employed. If employed, please give salary and the name and address of place(s) of employment.

Full Name and Address of Employer

Earnings Per Week

(Approximate)

50) My parent’s assets in the United States and other countries not including clothing and household necessities are:

Assets of father consist of the following:

Assets of mother consist of the following:

Cash, Stocks, and Bonds................................ $

Real Estate...................................................... $

Auto (dollar value minus amount owed) ....... $

Other (describe on line below)....................... $

TOTAL $

PART 7 - MISCELLANEOUS INFORMATION

(Continued on page 6)

51) I

- have

- have not entered the United States as a crewman after June 30, 1964.

52) I

- have

- have not been admitted as, or after arrival in the United States acquired the status of, an exchange alien.

53) I

- have

- have not submitted address reports as required by section 265 of the Immigration and Nationality Act.

54) I

- have

- have never (either in the United States or in any foreign country) been arrested, summoned into court as a defendant, con-

victed, fined, imprisoned, placed on probation, or forfeited collateral for an act involving a felony, misdemeanor, or breach of any public law or

ordinance (including, but not limited to, traffic violations or driving incidents involving alcohol). (If answer is in the affirmative, please

give a brief description of each offense including the name and location of the offense, date of conviction, any penalty imposed, any sentence

imposed, and the time actually served. You are required to submit documentation of any such occurances.)

No. If “Yes” please state branch (Army, Navy, etc.) and

55) Have you ever served in the Armed Forces of the United States?

Yes

service number:

Place of entry on duty:

(City and State)

Date of entry on duty:

Date of discharge:

(Month, Day, Year)

Type of discharge:

(Honorable, Dishonorable, etc.)

I served in active duty status from:

(Month, Day, Year)

56) Have you ever left the United States or the jurisdiction of the district where you registered for the draft to avoid being drafted into the military or

naval forces of the United States?

Yes

Form EOIR-42B

Please continue answers on a separate sheet as needed.

Revised July 2014

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