Form EOIR-42b Application for Cencellation of Removal and Adjustment o

U.S. Department of Justice
Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents

INFORMATION FOR APPLICANT

I.

PLEASE READ CAREFULLY. FEES WILL NOT BE RETURNED.

Aliens Eligible for Cancellation of Removal: You may be eligible to have your removal cancelled under
section 240A(b) of the Immigration and Nationality Act (INA). To qualify for this benefit, you must establish in a hearing before an Immigration Judge that:
A.

1.
2.
3.

OR
B.

4.
1.

2.

3.
4.
5.

Note:

6.

Prior to the service of the Notice to Appear, you have maintained continuous physical presence
in the United States for ten (10) years or more, and you have been a person of good moral character as defined in section 101(f) of the INA during such period;
You have not been convicted of an offense covered under sections 212(a)(2), 237(a)(2), or
237(a)(3) of the INA;

Your removal would result in exceptional and extremely unusual hardship to your United States
citizen or lawful permanent resident spouse, parent, or child; and
You are deserving of a favorable exercise of discretion.

You have been battered or subjected to extreme cruelty in the United States by your United States
citizen or lawful permanent resident spouse or parent, or you are the parent of a child of a United
States citizen or lawful permanent resident and the child has been battered or subjected to extreme
cruelty in the United States by such citizen or lawful permanent resident parent;

You have been physically present in the United States for a continuous period of not less than
3 years immediately preceding the dates of this application. The issuance of a charging document for removal proceedings (such as a Notice to Appear) shall not suspend the 3-year period
of continuous physical presence in the United States.
You have been a person of good moral character, as defined in section 101(f) of the INA during
the three years prior to the date of this application, subject to the provisions of section
240A(b)(2)(C) of the INA.

You are not inadmissible under sections 212(a)(2) or 212(a)(3) of the INA, you are not deportable
under section 237(a)(1)(G) or sections 237(a)(2)-(4) of the INA, and you have not been convicted of
an aggravated felony as defined under the INA;
a. Your removal would result in extreme hardship to you or your child who is the child of a United
States citizen or lawful permanent resident; or
b. You are a child whose removal would result in extreme hardship to you or your parent; and

You are deserving of a favorable exercise of discretion on your application.

If you have served on active duty in the Armed Forces of the United States for at least 24 months,
you do not have to meet the requirements of continuous physical presence in the United States.
You must, however, have been in the United States when you entered the Armed Forces. If you
are no longer in the Armed Forces, you must have been separated under honorable conditions.
Form EOIR-42B
Revised June 2012

U.S. Department of Justice
Executive Office for Immigration Review
II.

OMB#ll25-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents

Aliens NOT Eligible for Cancellation of Removal: You are not eligible for cancellation of removal
under section 240A(b)(1) of the INA if you:
A.

Entered the United States as a crewman after June 30, 1964;

B.

Were admitted to the United States as, or later became, a nonimmigrant exchange alien as defined in
section 101(a)(15)(J) of the INA in order to receive graduate medical education or training, regardless
of whether you are subject to or have fulfilled the 2-year foreign residence requirement of section
212(e) of the INA;

C.

D.
E.
F.

III.

Were admitted to the United States as, or later became, a nonimmigrant exchange alien as defined in
section 101(a)(15)(J) of the INA, other than to receive graduate medical education or training, and are
subject to the 2-year foreign residence requirement of section 212(e) of the INA, but have neither fulfilled nor obtained a waiver of that requirement;
Are an alien who is either inadmissible under section 212(a)(3) of the INA or deportable under
section 237(a)(4) of the INA;

Are an alien who ordered, incited, assisted, or otherwise participated in the persecution of an individual
because of the individual’s race, religion, nationality, membership in a particular social group, or
political opinion; or

Are an alien who was previously granted relief under section 212(c) of the INA, or section 244(a) of
the INA as such sections were in effect prior to the enactment of the Illegal Immigration Reform and
Immigrant Responsibility Act of 1996, or whose removal has previously been cancelled under section
240A of the INA.

How to Apply for Cancellation of Removal

If you believe that you have met all the requirements for cancellation of removal, you must answer all the
questions on the attached Form EOIR-42B fully and accurately. You must pay the filing and biometrics fees
and comply with the Department of Homeland Security (DHS) instructions for providing biometric and
biographic information to USCIS, [available at http://uscis.gov]. You must also serve a copy of your application
on the Assistant Chief Counsel for the DHS, U.S. Immigration and Customs Enforcement (ICE) as required in
the proof of service on page 8 of this application, and you must file your application with the appropriate
Immigration Court. Please read the following instructions carefully before completing your application.

Form EOIR-42B
Revised June 2012

U.S. Department of Justice
Executive Office for Immigration Review

1. PREPARATION OF APPLICATION.

OMB#ll25-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents
INSTRUCTIONS

To apply for cancellation of removal under section 240A(b) of the Immigration and Nationality Act (INA), you must fully
and accurately answer all questions on the attached Form EOIR-42B. You must also comply with all of the instructions
contained in this form. These instructions have the force of law. A separate application must be prepared and executed for
each person applying for cancellation of removal. An application on behalf of an alien who is mentally incompetent or is a
child under 14 years of age shall be executed by a parent or guardian.
Your responses must be typed or printed legibly in ink. Do not leave any questions unanswered or blank. If any
questions do not apply to you, write "none" or "not applicable" in the appropriate space.

To the extent possible, answer all questions directly on the form. If there is insufficient room to respond fully to a
question, please continue your response on an additional sheet of paper. Please indicate the number of the question being
answered next to your response on the additional sheet, write your alien registration number, print your name, and sign,
date, and securely attach each additional sheet to the Form EOIR-42B.

2. BURDEN OF PROOF.

The burden of proof is on you to prove that you meet all of the statutory requirements for cancellation of removal for
certain nonpermanent resident aliens under section 240A(b) of the INA and that you are entitled to such relief as a matter of discretion. To meet this burden, your responses to the questions on the application should be as detailed and complete as possible. You should also attach to your application any documents that demonstrate your eligibility for cancellation of removal (see "SUPPORTING DOCUMENTS" below).

3. SUPPORTING DOCUMENTS.

You should submit documentary evidence to show that you have maintained continuous physical presence in the United
States for the required period. Documents which may show evidence of your physical presence in the United States
include, but are not limited to, bankbooks, leases, deeds, licenses, receipts, letters, birth records, church records, school
records, employment records, and evidence of tax payments.

You should submit documents which help to show that you are, and have been, a person of good moral character during
the entire period of continuous physical presence in the United States required for eligibility for cancellation of removal.
You should submit police records from each jurisdiction in which you resided during such period. To show good moral
character, it is recommended that you submit the affidavits of witnesses attesting to your good moral character, preferably
citizens of the United States, and if you are employed, your employer. The affidavit from your employer should include
information regarding the nature and duration of your employment and your earnings.

For "Cancellation of Removal and Adjustment of Status for Certain Nonpermanent Residents," you are required to show
that your legal permanent resident or U.S. citizen husband/wife, mother, father and/or child would suffer exceptional and
extremely unusual hardship if you were removed from the U.S. To show exceptional and extremely unusual hardship,
you should present evidence (e.g., documents, testimony) that shows the person would suffer more than a normal person
would when a family member departs the U.S. For "Special Rule for Battered Spouse or Child," you should submit documents that would help to show that you and/or your child would suffer extreme hardship if you were removed. For each
of these, there are various types of hardship such as emotional, financial or medical. It is recommended that you submit
certified documents, affidavits, notarized letters, and/or medical records to help prove the exceptional and extremely unusual
hardship or the extreme hardship required. For Special Rule cases, the hardship can be related to the battery or extreme cruelty.

Form EOIR-42B
Revised June 2012

U.S. Department of Justice
Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents

You should submit official certification to establish your relationship to those you claim would suffer hardship by your
removal, and if such persons are citizens of the United States or lawful permanent residents, evidence of their citizenship
or lawful permanent resident status. Documentary evidence of such relationships may include, but are not limited to, birth
records, marriage certificates, proof of divorce or termination of marriage, and death certificates.

You should also submit with your application copies of any documents which you were issued by the Department of
Homeland Security (DHS), formerly the Immigration and Naturalization Service. The Immigration Judge may require you
to submit additional records relating to your request for cancellation of removal. These documents may include, but are not
limited to, documents which reflect payment of taxes, court convictions, and payment of child support during your physical presence in the United States.

The original of all supporting documents must be available for inspection at the hearing. If you wish to have the original
documents returned to you, you should also present reproductions.

4. REQUIRED BIOMETRIC AND BIOGRAPHIC INFORMATION.

Each applicant 14 years of age or older must also comply with the requirement to supply biometric and biographic information. You will be given instructions on how to complete this requirement. You will be notified in writing of the location of the Application Support Center (ASC) or the designated Law Enforcement Agency where you must go to provide
biometric and biographic information. You will also be given a date and time for the appointment. It is important to furnish all the required information. Failure to comply with this requirement may result in a delay in your application or in
your application being deemed abandoned and dismissed by the Immigration Court.

5. TRANSLATIONS.

Any document in a foreign language must be accompanied by an English language translation and a certificate signed by
the translator stating that he/she is competent to translate the document and that the translation is true and accurate to the
best of the translator's abilities. Such certification must be printed legibly or typed.

6. PHOTOGRAPHS.

Unless you are incarcerated or detained in a facility which prevents your compliance with this instruction, you must submit two glossy, unretouched, color photographs of yourself taken within 30 days of the date of this application. These
photos must have a white background and must not be mounted. The dimension of your facial image in the photograph
should be about one (1) inch from the chin to the top of your hair and you should be shown in full frontal/passport-style
view with your eyes open. Using a pencil or felt pen, you should lightly print your name and alien registration number
on the back of each photograph.

7. FEES.

Before you file your Form EOIR-42B with the Immigration Court, you must pay the required $100 filing fee and the
biometrics fee to the Department of Homeland Security (DHS). Evidence of payment of these fees in the form of a copy
of the DHS, U.S. Citizenship and Immigration Services (USCIS) ASC notice of fee receipt and biometrics appointment
instructions must accompany your Form EOIR-42B. These fees will not be refunded, regardless of the action taken on
your application. Therefore, it is important that you read the advice, instructions, and application carefully before
responding. If you are unable to pay the filing fee, you may ask the Immigration Judge to permit you to file your
Form EOIR-42B without fee (fee waiver).

DO NOT SEND CASH. All fees must be submitted in the exact amount. Remittance may be made by personal check,
cashier's check, certified bank check, bank international money order, or foreign draft drawn on a financial institution in
the United States and payable to the "Department of Homeland Security'' in United States currency. If the applicant
resides in the Virgin Islands, the check or money order must be payable to the "Commissioner of Finance of the Virgin
Islands." If the applicant resides in Guam, the check or money order must be made payable to the "Treasurer, Guam."

Form EOIR-42B
Revised June 2012

U.S. Department of Justice
Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents

Personal checks are accepted subject to collectibility. If your application fee check is returned for insufficient funds or
otherwise denied for payment, your application and any related documents will be invalid. A charge of $30.00 will be
imposed if a check in payment of a fee is not honored by the bank on which it is drawn. When the check is drawn on an
account of a person other than the applicant, the name and alien registration number of the applicant must be entered on
the face of the check. All checks must be drawn on a bank located in the United States.

8. SERVING & FILING YOUR APPLICATION.
A.
B.

You must first comply with the DHS instructions for providing biometric and biographic information to
USCIS, which involves sending a copy of the application to the appropriate USCIS Service Center. The
DHS instructions also address payment of the application fees.

You must then serve the following documents on the Assistant Chief Counsel for DHS, U.S. Immigration
and Customs Enforcement (ICE):

- a copy of your Form EOIR-42B, Application for Cancellation of Removal, with all supporting documents and additional sheets;

- a copy of the USCIS ASC notice of fee receipt and biometrics appointment instructions;

- the original Biographical Information Form G-325A; and

- a photograph of you which meets the requirements of instruction #6 above.

You must file the following documents with the appropriate Immigration Court:

- the original Form EOIR-42B with all supporting documents and additional sheets;

- a copy of the USCIS ASC notice of fee receipt and biometrics appointment instructions;
- a copy of Biographical Information Form G-325A;

- a photograph of you which meets the requirements of instruction #6 above; and

- a completed certificate showing service of these documents (See Part 10 of the Application on page 8)
on the ICE Assistant Chief Counsel, unless service is made on the record at the hearing.

Retain your USCIS ASC biometrics confirmation document or a copy of your Fingerprint Card, FD-258, if applicable,
as proof that your biometrics were taken, and bring it to your future Immigration Court hearings.

9. PENALTIES.

You must answer all questions on Form EOIR-42B truthfully and submit only genuine documents in support of your
application. You will be required to swear or affirm that the contents of your application and the supporting documents are true to the best of your knowledge. Your answer to the questions on this form and the supporting documents
you present will be used to determine whether your removal should be cancelled and whether you should be permitted to
adjust your status. Any answer you give and any supporting document you present may also be used as evidence in any
proceeding to determine your right to be admitted or readmitted, re-enter, pass through, or reside in the United States. Your
application may be denied if any of your answers or supporting documents are found to be false.

Presenting false answers or false documents may also subject you to criminal prosecution under 18 U.S.C. section 1546
and/or subject you to civil penalties under 8 U.S.C. section 1324c. Specifically, if you submit your application knowing
that the application, or any supporting document, contains any false statement with respect to a material fact, or if you
swear or affirm that the contents of your application and the supporting documents are true, knowing that the application
or any supporting documents contain any false statement with respect to a material fact, you could be liable under these
provisions. If convicted, you could be fined up to $250,000, imprisoned for up to ten (10) years, or both. 18 U.S.C. sections 1546(a), 3559(a)(4), 3571(b)(3). If it is determined you have violated the prohibition against document fraud and a

Form EOIR-42B
Revised June 2012

U.S. Department of Justice
Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents

final order is entered against you, you could be subject to a civil penalty up to $2,000 for each document used or created
for the first offense, and up to $5,000 for any second, or subsequent offense. In addition, if you are the subject of a final
order for violating 8 U.S.C. section 1324c, relating to civil penalties for document fraud, you will be removable from the
United States.

10. PAPERWORK REDUCTION ACT NOTICE.

Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays
a currently valid OMB control number. We try to create forms and instructions that are accurate, can easily be understood, and which impose the least possible burden on you to provide us with information. Often, this process is difficult
because some immigration laws are very complex. The reporting burden for this collection of information is computed
as follows: (1) learning about the form, 50 minutes, (2) completing the form, 2 hours, and (3) assembling and filing the
form, 3 hours, for an average of 5 hours, 50 minutes per application. If you have comments regarding the accuracy of
this burden estimate, or any other aspect of this collection of information, including suggestions for reducing this burden, you may write to the U.S. Department of Justice, Executive Office for Immigration Review, Office of the General
Counsel, 5107 Leesburg Pike, Suite 2600, Falls Church, Virginia 22041.

11. PRIVACY ACT NOTICE.

The information on this form is authorized by 8 U.S.C. § 1229b in order to apply for Cancellation of Removal. The
information you provide is required to obtain the relief of Cancellation of Removal and failure to provide the requested
information may result in denial of your request. EOIR may share this information with others in accordance with
approved routine uses described in EOIR systems of records notices.

Form EOIR-42B
Revised June 2012

OMB#ll25-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents

U.S. Department of Justice
Executive Office for Immigration Review

PLEASE READ INFORMATION AND
INSTRUCTIONS BEFORE FILLING IN FORM

Fee Stamp (Official Use Only)

PLEASE TYPE OR PRINT

PART 1 - INFORMATION ABOUT YOURSELF

1) My present true name is: (Last, First, Middle)

2) Alien Registration or “A” Number(s):

3) My name given at birth was: (Last, First, Middle) or same as #1 ❏

4) Birth Place: (CIty and Country)

5) Date of Birth: (Month, Day, Year)

6) Gender:

7) Height:

10) a) Current Nationality:
b) Current Citizenship:

11) Social Security Number:

❏ Male

❏ Female

8) Hair Color:

12) Home Phone Number:

(

)

9) Eye Color:

13) Work Phone Number:

(

)

14) I have been known by these additional name(s):

15) I have resided in the following locations in the United States: (List PRESENT ADDRESS FIRST, and work back in time for at least 10 years).
Street and Number - Apt. or Room# - City or Town - State - Zip Code

Please continue answers on a separate sheet as needed.
(1)

Resided From:

(Month, Day, Year)

Resided To:

(Month, Day, Year)

PRESENT

Form EOIR-42B
Revised June 2012

PART 2 - INFORMATION ABOUT THIS APPLICATION

16) I, the undersigned, hereby request that my removal be cancelled under the provisions of section 240A(b) of the Immigration and Nationality
Act (INA). I believe that I am eligible for cancellation of removal because: (Check all that apply.)

❏

My removal would result in exceptional and extremely unusual hardship to my:
UNITED STATES
CITIZEN

spouse, who is a

LEGAL PERMANENT
RESIDENT

TEMPORARY
STATUS

NO
STATUS

father, who is a

mother, who is a

child/children, who is/are a
With the exception of absences described in question #23, I have resided in the United States since:

❏

(Month, Day, Year)

.

I, or my child, have been battered or subjected to extreme cruelty by a United States citizen or lawful permanent resident spouse or parent.

With the exception of absences described in question #23, I have resided in the United States since:

.

(Month, Day, Year)

PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES

17) I first arrived in the United States under the name of: (Last, First, Middle)
19) Place or port of first entry: (Place or Port, City, and State)

18) I first arrived in the United States on: (Month, Day, Year)

20) Select a, b, or c:
I: a) ❏ was inspected and admitted.
❏ I entered using my Lawful Permanent Resident card which is valid until
b)

❏

c)

❏

21) I applied on

❏

I entered using a

(Specify Type of Visa)

was not inspected and admitted.
❏ I entered without documents. Explain:
❏ I entered without inspection. Explain:
Other Explain:

and valid until

visa which is valid until

; or

(Month, Day, Year)

❏

.

(Month, Day, Year)

.
.

for additional time to stay and it was

(Month, Day, Year)

.

(Month, Day, Year)

❏

denied on

granted on

(Month, Day, Year)

(Month, Day, Year)

22) Since the date of my first entry, I departed from and returned to the United States at the following places and on the following dates:
(Please list all departures regardless of how briefly you were absent from the United States.)
If you have never departed from the United States since your original date of entry, please mark an X in the box: ❏
1
2

Port of Departure (Place or Port, City and State)

Departure Date (Month, Day, Year)

Purpose of Travel

Destination

Port of Return (Place or Port, City and State)

Return Date (Month, Day, Year)

Manner of Return

Port of Departure (Place or Port, City and State)

Departure Date (Month, Day, Year)

Purpose of Travel

❏ Yes ❏

Destination

Port of Return (Place or Port, City and State)

Return Date (Month, Day, Year)

Manner of Return

Inspected and Admitted?

23) Have you ever departed the United States:

.

Inspected and Admitted?
No

❏ Yes ❏ No
a) under an order of deportation, exclusion, or removal?................................... ❏ Yes ❏ No
b) pursuant to a grant of voluntary departure? ................................................... ❏ Yes ❏ No
c) voluntarily, other than by a grant of voluntary departure? ............................. ❏ Yes ❏ No

Please continue answers on a separate sheet as needed.
(2)

Form EOIR-42B
Revised June 2012

PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE

24) a) I am not married:
b) I am married:

❏

❏

c) I have a common-law spouse:

❏

25) If married, the name of my spouse is: (Last, First, Middle) 26) My spouse’s name before marriage was:

27) The marriage took place in: (City and Country)

28) Date of Marriage:

29) My spouse currently resides at:

30) Birth Date of Spouse: (Month, Day, Year)

Apt. number and/or in care of

(Month, Day, Year)

31) My spouse is a citizen of: (Country)

Number and Street
City or Town

State/Country

Zip Code

32) If your spouse is other than a native born United States citizen, answer the following:

.

a) He/she arrived in the United States at: (Place or Port, City and State)

.

b) He/she arrived in the United States on: (Month, Day, Year)
c) His/her alien registration number is: A#

d) He/she was naturalized on (Month, Day, Year)

33) My spouse is ❏ is not

.

at

(City and State)

❏ employed. If employed, please give salary and the name and address of the spouse’s place(s) of employment.
Full Name and Address of Spouse’s Employer

.

Earnings Per Week

$
$
$

(Approximate)

34) I have ❏ have not ❏ been previously married: (If previously married, list the name of each prior spouse, the dates on which each marriage
began and ended, the place where the marriage terminated, and describe how each marriage ended.)
Name of prior spouse: (Last, First, Middle)

Place marriage ended:

Date marriage began:
Date marriage ended:

(City and Country)

Description or manner of how marriage was
terminated or ended:

35) My present spouse has ❏ has not ❏ been previously married: (If spouse was previously married, list the name of each prior spouse, the dates on which
the marriage began and ended, the place where the marriage terminated, and describe how each marriage ended.)
Name of spouse’s prior spouse: (Last, First, Middle) Date marriage began:
Date marriage ended:

Place marriage ended:
(City and Country)

Description or manner of how marriage
was terminated or ended:

36) Have you been ordered by any court, or are otherwise under any legal obligation, to provide child support and/or spousal maintenance as a
❏ - Yes ❏ - No
result of a separation and/or divorce?

PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS (Continued on page 4)

37) Since my first 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

$

(Approximate)

Type of Work
Performed

Employed From:
(Month, Day, Year)

Employed To:

(Month, Day, Year)

PRESENT

$
$
Please continue answers on a separate sheet as needed.
(3)

Form EOIR-42B
Revised June 2012

PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS (Continued from page 3)
38) If self-employed, describe the nature of the business, the name of the business, its address, and net income derived therefrom:

39) My assets (and if married, my spouse’s assets) in the United States and other countries, not including clothing and household necessities, are:
Self
Cash, Stocks, and Bonds...................................... $
Real Estate (dollar value minus amount owed)...$
Auto (dollar value minus amount owed) ............ $
Other (describe on line below)............................ $
TOTAL $

Jointly Owned With Spouse
Cash, Stocks, and Bonds...................................... $
Real Estate (dollar value minus amount owed)...$
Auto (dollar value minus amount owed) ............ $
Other (describe on line below)............................ $
TOTAL $

40) I have ❏ have not ❏ received public or private relief or assistance (e.g., Welfare, Unemployment Benefits, Medicaid, TANF, AFDC, Housing
Subsidies and WIC Benefits 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 amount received during this time:
41) Please list each of the years in which you have filed an income tax return with the Internal Revenue Service:

PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued on page 5)

42) 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: (Last, First, Middle)
Child’s Alien Registration Number:

Citizen of What Country:
Birth Date: (Month, Day, Year)

Now Residing At: (City and Country)
Birth Place: (City and Country)

A#:
Estimated Total of Assets: $

Estimated Avg. Weekly Earnings: $

A#:
Estimated Total of Assets: $

Estimated Avg. Weekly Earnings: $

A#:
Estimated Total of Assets: $

Estimated Avg. Weekly Earnings: $

Sex

Male

Female
Male

Female
Male

Female

❏
❏

Immigration Status
of Child?

❏
❏
❏
❏

43) If your application is denied, would your spouse and all of your children accompany you to your:
a) Country of Birth b) Country of Nationality c) Country of Last Residence -

❏ Yes ❏ No

❏ Yes ❏ No

If you answered “No” to any of the
responses, please explain:

❏ Yes ❏ No

44) Describe in detail what specific hardship you or each of your United States Citizen or lawful permanent resident spouse, parent or child
would suffer if you were removed:

Please continue answers on a separate sheet as needed.
(4)

Form EOIR-42B
Revised June 2012

PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued from page 4)

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, Housing Subsidies and WIC Benefits, 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: (Last, First, Middle)
Alien Registration Number:

Citizen of What Country:
Birth Date: (Month, Day, Year)

A#:
/
Complete Address of Current Residence, if living:

/

A#:
/
Complete Address of Current Residence, if living:

/

Immigration Status
of Listed Relative

Relationship to Me:
Birth Place: (City and Country)

IF THIS APPLICATION IS BASED ON HARDSHIP TO A PARENT OR PARENTS, QUESTIONS 49-52 MUST BE ANSWERED.
47) If your parent is not a citizen of the United States, give the date and place of arrival in the United States, including full details as to the date,
manner, and terms of admission into the United States:

48) My father is ❏ is not ❏ employed. If employed, please give salary and the name and address of the place(s) of employment.
Full Name and Address of Employer

Earnings Per Week

$

(Approximate)

49) My mother is ❏ is not ❏ employed. If employed, please give salary and the name and address of the place(s) of employment.
Full Name and Address of Employer

Earnings Per Week

$

(Approximate)

50) My parent’s assets in the United States and other countries not including clothing and household necessities are:
Assets of father consist of the following:
Assets of mother consist of the following:
Cash, Stocks, and Bonds...................................... $
Cash, Stocks, and Bonds......................................$
Real Estate (dollar value minus amount owed)...$
Real Estate (dollar value minus amount owed)...$
Auto (dollar value minus amount owed) ............ $
Auto (dollar value minus amount owed) .............$
Other (describe on line below)............................ $
Other (describe on line below)............................ $
TOTAL $
TOTAL $

PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6)

51) I have ❏ have not ❏ entered the United States as a crewman after June 30, 1964.

52) I have ❏ have not ❏ been admitted as, or after arrival in the United States acquired the status of, an exchange alien.
Please continue answers on a separate sheet as needed.
(5)

Form EOIR-42B
Revised June 2012

PART 7 - MISCELLANEOUS INFORMATION (Continued from page 5)

53) I have ❏ have not ❏ submitted address reports as required by section 265 of the Immigration and Nationality Act.

54) I have ❏ have never ❏ (either in the United States or in any foreign country) been arrested, summoned into court as a defendant, convicted,
fined, imprisoned, placed on probation, or forfeited collateral for an act involving a felony, misdemeanor, or breach of any public law or ordinance
(including, but not limited to, traffic violations or driving incidents involving alcohol). (If answer is in the affirmative, please give a
brief description of each offense including the name and location of the offense, date of conviction, any penalty imposed, any sentence imposed,
and the time actually served.)

55) Have you ever served in the Armed Forces of the United States?
service number:
Place of entry on duty: (City and State)

Date of entry on duty: (Month, Day, Year)

❏ Yes ❏ No.

If “Yes” please state branch (Army, Navy, etc.) and

Date of discharge: (Month, Day, Year)

Type of discharge: (Honorable, Dishonorable, etc.)

I served in active duty status from: (Month, Day, Year)

to

(Month, Day, Year)

56) Have you ever left the United States or the jurisdiction of the district where you registered for the draft to avoid being drafted into the military or
naval forces of the United States?
❏ Yes ❏ No

57) Have you ever deserted from the military or naval forces of the United States while the United States was at war?

❏

❏ Yes ❏

No

59) Were you ever exempted from service because of conscientious objection, alienage, or any other reason?

❏ Yes ❏

No

58) If male, did you register under the Military Selective Service Act or any applicable previous Selective Service (Draft) Laws?
If “Yes,” please give date, Selective Service number, local draft board number, and your last draft classification:

Yes ❏ No

60) Please list your present or past membership in or affiliation with every political organization, association, fund, foundation, party, club, society,
or similar group in the United States or any other place since your 16th birthday. Include any foreign military service in this part. If none, write
“None.” Include the name of the organization, location, nature of the organization, and the dates of membership.
Name of Organization

61) Have you ever:
a)
b)

c)

Location of Organization

Nature of Organization

Member From:
(Month, Day, Year)

Member To:

(Month, Day, Year)

❏ Yes ❏ No
❏ Yes ❏ No
❏

Yes

❏

been ordered deported, excluded, or removed?
overstayed a grant of voluntary departure from an Immigration Judge or the Department of Homeland Security (DHS),
formerly the Immigration and Naturalization Service (INS)?
No failed to appear for deportation?
Please continue answers on a separate sheet as needed.
(6)

Form EOIR-42B
Revised June 2012

62) Have you ever been:

h)

❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes
❏ Yes

i)

Yes

a)

b)

c)

d)
e)
f)

g)

j)

k)

❏
❏

❏

Yes
Yes

❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

PART 7 - MISCELLANEOUS INFORMATION (Continued from page 6)

No

No
No

a habitual drunkard?

one whose income is derived principally from illegal gambling?

one who has given false testimony for the purpose of obtaining immigration benefits?

No

one who has engaged in prostitution or unlawful commercialized vice?

No

a polygamist?

No
No
No
No
No
No

involved in a serious criminal offense and asserted immunity from prosecution?
one who aided and/or abetted another to enter the United States illegally?

a trafficker of controlled substance, or a knowing assister, abettor, conspirator, or colluder with others in any such

controlled substance offense (not including a single offense of simple possession of 30 grams or less of marijuana)?

inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?

one who has ordered, incited, assisted, or otherwise participated in the persecution of an individual on account of his or
her race, religion, nationality, membership in a particular social group, or political opinion?

a person previously granted relief under former sections 212(c) or 244(a) of the INA or whose removal has previously
been cancelled under section 240A of the INA?

If you answered “Yes” to any of the above questions, explain:

63) Are you the beneficiary of an approved visa petition? ❏ Yes ❏ No
If yes, can you arrange a trip outside the United States to obtain an immigrant visa?

❏

Yes

❏

No

If no, please explain:

64) The following certificates or other supporting documents are attached hereto as a part of this application: (Refer to the Instructions for
documents which should be attached.)

Please continue answers on a separate sheet as needed.
(7)

Form EOIR-42B
Revised June 2012

PART 8 - SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT
(Read the following information and sign below)

I declare that I have prepared this application at the request of the person named in Part 1, that the responses provided are based
on all information of which I have knowledge, or which was provided to me by the applicant, and that the completed application was read to the applicant in a language the applicant speaks fluently for verification before he or she signed the application in my presence. I am aware that the knowing placement of false information on the Form EOIR-42B may subject me to
civil penalties under 8 U.S.C. 1324c.
Signature of Preparer:
Daytime Telephone #:
(

)

Print Name:

Date:

Address of Preparer: (Number and Street, City, State, Zip Code)

PART 9 - SIGNATURE

APPLICATION NOT TO BE SIGNED BELOW UNTIL APPLICANT APPEARS BEFORE
AN IMMIGRATION JUDGE

I swear or affirm that I know the contents of this application that I am signing, including the attached documents and supplements, and that they
are all true to the best of my knowledge, taking into account the correction(s) numbered
to
, if any, that were made by me or at
my request.
(Signature of Applicant or Parent or Guardian)
Subscribed and sworn to before me by the above-named applicant at
Immigration Judge
Date (Month, Day, Year)

PART 10 - PROOF OF SERVICE
I hereby certify that a copy of the foregoing Form EOIR-42B was:
on
at

(Month, Day, Year)

❏

- delivered in person

❏

- mailed first class, postage prepaid

to the Assistant Chief Counsel for the DHS (U.S. Immigration and Customs Enforcement - ICE)
(Number and Street, City, State, Zip Code)

Signature of Applicant (or Attorney or Representative)
Please continue answers on a separate sheet as needed.
(8)

Form EOIR-42B
Revised June 2012