Form Eoir-42b - Application For Cancellation Of Removal And Adjustment Of Status For Certain Nonpermanent Residents Page 8

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PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE

(Continued)

35) I

- have

- have not been previously married: (If previously married, list the name of each prior spouse, the dates on which each mar-

riage began and ended, the place where the marriage terminated, and describe how each marriage ended.)

Name of prior spouse:

Place marriage ended:

Date marriage began:

Description or manner of how marriage was

(Last, First, Middle)

Date marriage ended:

terminated or ended:

(City and Country)

36) My present spouse

- has

- has not been previously married: (If previously married, list the names of each prior spouse, the dates on

which each marriage began and ended, the place wher e the marriage terminated, and describe how each marriage ended.)

Name of prior spouse:

Place marriage ended:

Date marriage began:

Description or manner of how marriage was

(Last, First, Middle)

Date marriage ended:

terminated or ended:

(City and Country)

37) Have you been ordered by any court, or are otherwise under any legal obligation, to provide child support and/or spousal maintenance as a

result of a separation and/or divorce?

Yes

PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS

38) Since my arrival into the United States, I have been employed by the following named persons or firms: (Please begin with present employment and

work back in time. Any periods of unemployment or school attendance should be specified. Attach a separate sheet for additional entries if necessary .)

Full Name and Address of Employer

Earnings Per Week

Type of Work

Employed From:

Employed To:

Performed

(Approximate)

(Month, Day, Year)

PRESENT

39) If self-employed, describe the nature of the business, the name of the business, its address, and net income derived therefrom:

40) My assets (and if married, my spouse’s assets) in the United States and other countries, not including clothing and household necessities, are:

Self

Jointly Owned With Spouse

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

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

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

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

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

TOTAL $

41) I

- have

- have not received public or private relief or assistance (e.g. Welfare, Unemployment Benefits, Medicaid, TANF, AFDC,

etc.). If you have, please give full details including the type of relief or assistance received, date for which relief or assistance was received, place,

and total amount received during this time:

42) Please list each of the years in which you have filed an income tax return with the Internal Revenue Service:

Please continue answers on a separate sheet as needed.

Form EOIR-42B

Revised July 2014

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