Form Eoir-42b - Application For Cancellation Of Removal And Adjustment Of Status For Certain Nonpermanent Residents Page 6

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OMB#ll25-0001
U.S. Department of Justice
Application for Cancellation of Removal and Adjustment
Executive Office for Immigration Review
of Status for Certain Nonpermanent Residents
PLEASE READ ADVICE AND INSTRUCTIONS
Fee Stamp (Official Use Only)
BEFORE FILLING IN FORM
PLEASE TYPE OR PRINT
PART 1 - INFORMATION ABOUT YOURSELF
1) My present true name is:
2) Alien Registration (or “A”) Number(s):
(Last, First, Middle)
3) My name given at birth was:
(Last, First, Middle)
4) Birth Place:
(City and Country)
5) Date of Birth:
6) Gender:
7) Height:
8) Hair Color:
9) Eye Color:
(Month, Day, Year)
J Male
J Female
12) Home Phone Number:
13) Work Phone Number:
10) Current Nationality and Citizenship:
11) Social Security Number:
(
)
(
)
14) I currently reside at:
15) I have been known by these additional name(s):
Apt. number and/or in care of
Number and Street
City or Town
State
Zip Code
16) I have resided in the following locations in the United States: (List PRESENT ADDRESS FIRST, and work back in time for at least 10
years.)
Street and Number - Apt. or Room # - City or Town - State - Zip Code
Resided From:
Resided To:
(Month, Day, Year)
(Month, Day, Year)
PRESENT
PART 2 - INFORMATION ABOUT THIS APPLICATION
17) I, the undersigned, hereby request that my removal be cancelled under the provisions of section 240A(b) of the Immigration and Nationality
Act (INA). I believe that I am eligible for cancellation of removal because: (Check all that apply.)
J
My removal would result in exceptional and extremely unusual hardship to my:
UNITED STATES
LEGAL PERMANENT
TEMPORARY
NO
CITIZEN
RESIDENT
STATUS
STATUS
spouse, who is a
father, who is a
mother, who is a
child/children, who is/are a
With the exception of absences described in question #23, I have resided in the United States since:
(Month, Day, Year)
.
J
I, or my child, have been battered or subjected to extreme cruelty by a United States citizen or lawful permanent resident spouse or parent.
With the exception of absences described in question #23, I have resided in the United States since:
.
(Month, Day, Year)
Form EOIR-42B
Please continue answers on a separate sheet as needed.
Revised July 2014
(1)

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