Form I-243 - Application For Removal Page 2
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1
2Certificate of Accredited Representative of Public or Charitable Institution
From Which Alien Named Has Received Aid
I,
, being an accredited representative
(Name of Accredited Representative)
of
(Give name of institution or association with which connected)
hereby certify that the said
, an applicant for removal
under section 250 of the Immigration and Nationality Act, has received the following aid or assistance from the:
(Signature)
Date
(Title)
Our Authority to Collect This Information: The authority for collection of the information requested on this form is contained in
8 U.S.C. 1260. Submission of the information by an alien applicant for removal from the United States at U.S. Government expense is
voluntary. The solicited information will be used principally by the Department of Homeland Security (DHS) to determine whether the
applicant is eligible for removal from the United States under the provisions of section 250 of the Immigration and Nationality Act,
8 U.S.C. 1260. The information may also as a matter of routine use be disclosed to other Federal, state, local, and foreign law
enforcement and regulatory agencies, the Department of Defense including any component thereof (if the applicant has served or is
serving in the Armed Forces of the United States), the U.S. Department of State, Central Intelligence Agency, Interpol, and by
individuals and organizations during the course of investigation to elicit further information required by the DHS to carry out its
functions. Failure to provide any or all of the solicited information may result in the denial of the application for removal from the
United States.
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at
30 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
U.S. Citizenship and Immigration Services, Regulatory Products Division, Office of the Executive Secretariat, 20 Massachusetts
Avenue, N.W., Washington, DC 20529-2020. OMB No. 1615-0019. Do not mail your application to this address.
Form I-243 (Rev. 12/20/10) Y Page 2
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