Form I-243 Application for Removal

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OMB No. 1615-0019; Expires 08-31-08

Department of Homeland Security
U.S. Citizenship and Immigration Services

I-243, Application for Removal

NOTE: Complete the 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 age 14 years 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 in capital letters)

(First Name)

3. Present Address (Apt. No.)

(Number and Street)

4. Date of Birth

5. Place of Birth (City or Town)

6. Date of Entry into U.S.

Port-of-Entry

7. Status at Entry ("X" one)

8. I
10.

do

I

2.

(Middle Name)

File Number (Alien Registration Number)

(City or Town)

(Country)

(Country, Province or State)

(Country of Citizenship/Nationality)

Name of vessel, airlline or other means of conveyance

Temporary
Permanent
Entered Without Inspection
Visitor
Resident
Please attach any documents issued to you at time of entry
do not

have a Permanent Resident Card.

I
9. I
have
been issued a Reentry Permit.

Removal is requested to: (City or town)

have not

(Country, district, province or state)

11. I
do
I
do not have a Valid Passport or Travel
Document for entry into the country shown above.
13. The persons listed below depend on me for support: (If, none, so state)
Name

Other (Specify)
______________________

Age

12. I
have
I
have not
previously filed an application for removal.
Will
Accompany You
Yes
No

Address

Relationship

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

Name

Complete Address

Relationship

15. I
have
have not
received assistance from a public or charitable insitution 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.
Name of institution or association

Complete Address

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.
(Signature of Preparer)
(

)
(Telephone Number)

(Address)

(Date)

E-mail address (If any)
Form I-243 (Rev. 02/28/05)N

Certificate of Accredited Representative of Public or Charitable Institution
From Which Alien Named Has Received Aid
I, _______________________________________________________, being an 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:
__________________________________________________________________________________________
(Name of institution or association)
_______________________________________________________________________________________________________
(Nature and period(s) of such aid)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_______________________________________________________

(Name)

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, 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.

Reporting Burden: Under the Paperwork Reduction Act, an agency may not conduct or sponsor an information
collection and a person is not required to respond to an information collection unless it displays a currently valid OMB
control number. We try to create forms and instructions that are accurate, can be easily understood and that impose the
least possible burden on you to provide us with information. Often this is difficult because some immigration laws
are very complex. The estimated average time to complete and file this application is 30 minutes per application.
If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you may
write to the U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachuets Avenue
N.W., Washington, DC 20529; OMB No. 1615-0019. Do not mail your completed application to this address.
Form I-243 (Rev. 02/28/05)N Page 2