Form G-146 Non-Immigrant Checkout Letter

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement
NON-IMMIGRANT CHECKOUT LETTER
OMB No. 1653-0020
Expires 09/30/2011

DHS Office Address

File Number
Date

This Section To Be Completed by Enforcement and Removal Operations
The records of this office of the Department of Homeland Security show that permission was granted to
to remain in the United States for a temporary period.
The office has no records of his, her, or their departure from the United States.
To assist in the completion of our records relating to the departure of temporary visitors, you are requested to complete
this form and:
Return it in the attached self-addressed envelope. No postage is required if mailed from anywhere in the United States.
Mail or take it to the office of the nearest American Consul and ask him or her to return it to this office.
Your cooperation in this matter is appreciated.
This Section To Be Completed By Any Authorized U.S. Official
Select and complete all parts of the statement below that accurately reflect your knowledge about this person(s).
(NOTE: If Form I-94, Arrival-Departure Record, is available, please attach it to this form.)

The person(s) inquired about:

Departed from the United States at
On

Date

Port of Departure

via

Name of Vessel or other means of transportation

Applied for or has been granted an extension of temporary stay at the
Location

Office of the Department of Homeland Security.
Applied for adjustment of status at the
Location

Office of the Department of Homeland Security.
Did not depart from the United States.
Can be contacted at the following address:
Address

City

State or Province

Zip Code

Country

Has or have the following friends or relatives in the United States who may have information concerning his, her, or
their whereabouts:
Name

Address

City

State

Zip Code

Name

Address

City

State

Zip Code

ICE Form G-146 (Rev. 7/11)

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None of the above items apply but the following information is provided: (Attach additional sheet(s) of paper if necessary.)

None of the above items apply and I have no information to provide relating to this person(s).
Printed Name and Signature
Address
City

State

Zip Code

NOTE: The provision for collecting this information is voluntary. You are under no legal obligation to complete this form.

Public Reporting Burden. U.S. Immigration and Customs Enforcement is collecting this information as a part
of its agency mission under the Department of Homeland Security. The estimated average time to review the
instructions, search existing data sources, gather and maintain the data needed and completing and reviewing
this collection of information is 10 minutes (0.166 hours) per response. An agency may not conduct or sponsor,
and a person is not required to respond to, an information collection unless it displays a currently valid OMB
Control Number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to:
Office of the Chief Financial Officer/OAA/Records Branch
U.S. Immigration and Customs Enforcement,
500 12th Street, SW STOP 5705
Washington, D.C. 20536-5705
(Do not mail this completed form to this address.)

ICE Form G-146 (Rev. 7/11)

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