Form I-243 Application for Removal

OMB No. 1615-0019; Expires 12/31/2012
Department of Homeland Security
U.S. Citizenship and Immigration Services

I-243, Application for Removal

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.
(First Name)

1. Name (Family Name)
3. Present Address (Number and Street)
4.

Date of Birth (mm/dd/yyyy)

File Number (Alien Registration Number)
(Country)

(Country, Province, or State)

Place of Birth (City or Town)
Port-of-Entry

7. Status at Entry (Please select one)

2.

(City or Town)

(Apt. No.)

5.

6. Date of Entry into U.S (mm/dd/yyyy).

(Middle Name)

(Country of Citizenship/Nationality)

Name of vessel, airline, or other means of conveyance

Permanent Resident

Temporary Visitor

Entered Without Inspection

Other (Specify)

Please attach any documents issued to you at time of entry
8. Do you have a Permanent Resident Card?

9. Have you been issued a Reentry Permit?
Yes

10.

No

Yes
(Country, district, province, or state)

Removal is requested to: (City or town)

11. Do you have a Valid Passport or Travel Document for
entry into the country shown above?

12. Have you previously filed an Application for
Removal?

No

Yes

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

14.

No

Age

No

Yes

Will They Accompany You?

Relationship

Address

Yes

No

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

Name

Age

Relationship

Address

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
No
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)

18. SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT: 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)

(Date)

(Address)

(Printed Name)

)

-

(Telephone Number)

E-mail address (If any)
Form I-243 07/23/12 Y Page 1

Certificate 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 Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue
NW, Washington, DC 20529-2020. OMB No. 1615-0019. Do not mail your application to this address.

Form I-243 07/23/12 Y Page 2