Form Eoir-42b - Application For Cancellation Of Removal And Adjustment Of Status For Certain Nonpermanent Residents Page 9

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PART 6 - INFORMATION ABOUT YOUR FAMILY

(Continued on page 5)

43) I have

(Number of) children. Please list information for each child below, include assets and earnings information for

children over the age of 16 who have separate incomes:

Name of Child:

Citizen of What Country:

Now Residing At:

Immigration Status

(Last, First, Middle)

(City and Country)

Child’s Alien Registration Number:

Birth Date:

of Child

(Month, Day, Year)

(City and Country)

A#:

Estimated Total of Assets: $

Estimated Average Weekly Earnings: $

A#:

Estimated Total of Assets: $

Estimated Average Weekly Earnings: $

A#:

Estimated Total of Assets: $

Estimated Average Weekly Earnings: $

44) If your application is denied, would your spouse and all of your children accompany you to your:

If you answered “No” to any of the

Country of Birth -

Yes

responses, please explain:

Country of Nationality -

Yes

Country of Last Residence -

Yes

45) Members of my family, including my spouse and/or child(ren)

- have

- have not received public or private relief or assistance (e.g.,

Welfare, Unemployment Benefits, Medicaid, TANF, AFDC, etc.). If any member of your immediate family has received such relief or assistance, please

give full details including identity of person(s) receiving relief or assistance, dates for which relief or assistance was received, place, and

total amount received during this time:

46) Please give the requested information about your parents, brothers, sisters, aunts, uncles, and grandparents, living or deceased. As to residence,

show street address, city, and state, if in the United States; otherwise show only country:

Name:

Citizen of What Country:

Relationship to Me:

Immigration Status

(Last, First, Middle)

Alien Registration Number:

Birth Date:

of Listed Relative

(Month, Day, Year)

(City and Country)

A#: