Form I-243 - Application For Removal

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OMB No. 1615-0019; Expires 12/31/2012

Department of Homeland Security

I-243, Application for Removal

U.S. Citizenship and Immigration Services

NOTE: Complete your application in duplicate. Take or mail it to a Department of Homeland Security office nearest your place of residence. A

separate application must be filed by each applicant, except that children under 14 years of age may be included in a parent's application.

Applicant's Request for Removal: Being in distress or in need of public aid from causes arising after entry, I hereby request to be

removed from the United States at government expense.

1. Name (Family Name)

(First Name)

(Middle Name)

File Number (Alien Registration Number)

(Country)

(City or Town)

3. Present Address (Apt. No.)

(Number and Street)

(Country, Province, or State)

5. Place of Birth (City or Town)

(Country of Citizenship/Nationality)

Date of Birth

(mm/dd/yyyy)

Name of vessel, airline, or other means of conveyance

Port-of-Entry

6. Date of Entry into U.S

(mm/dd/yyyy).

7. Status at Entry (Please select one)

Permanent

Temporary

Other (Specify)

Entered Without Inspection

Visitor

Resident

_____________________

Please attach any documents issued to you at time of entry

Do you have a Permanent Resident Card?

Have you been issued a Reentry Permit?

Yes

(Country, district, province, or state)

10.

Removal is requested to: (City or town)

11. Do you have a Valid Passport or Travel Document for

12.

Have you previously filed an Application for Removal?

Yes

entry into the country shown above?

Yes

13. The persons listed below depend on me for support: (If none, write "None")

Will They Accompany You?

Name

Address

Age

Relationship

Yes

14. List your nearest relatives in the country to which removal is requested:

Age

Address

Name

Relationship

15.

Have you received assistance from a public or charitable institution association? (If so, complete the following and have an official of such organization complete

the certificate on the reverse side. If not, skip to Question 16.)

Yes

Complete Address

Name of Institution or Association

16. If you have not received such assistance, indicate the financial circumstances that cause you to need public aid and attach any documentary evidence

available to support your statements.

17. APPLICANT'S CERTIFICATION: I understand that if this application is granted, and I am removed from the United States, I will be ineligible to apply

for or receive a visa or other documents for readmission, or to apply for admission to the United States, except with the prior approval of the Secretary of the

Department of Homeland Security. I certify that the above statements are true and correct to the best of my knowledge and belief.

(Signature of Applicant)

(Date)

Signature of person preparing form, if other than applicant

18.

I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge.

(Printed Name)

(Address)

(Date)

(

)

(Telephone Number)