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 03/31/2017

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

Port of Departure

via

Name of Vessel or other means of transportation

Date

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 (5/17)

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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 (Sign in ink)

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 Information Officer/Forms Management
U.S. Immigration and Customs Enforcement,
801 I Street, NW STOP 5800
Washington, D.C. 20536-5800
(Do not mail this completed form to this address.)
PRIVACY ACT STATEMENT
AUTHORITY: U.S. Immigration and Customs Enforcement (ICE) is authorized to collect this information by and through
the following authorities: sections 101, 222(g), 212(a)(9)B(i)(I) and (II), 214(a)(1), and 217(a)(7) of the Immigration and
Nationality Act; and 8 C.F.R. § 215.8(a)(1) and 235.1(f)(1)(ii).
PURPOSE: The purpose of the form is to verify that an alien voluntarily departed the United States pursuant to an order
from an Immigration Judge; or to document that an alien did not depart the United States for a valid reason; or to obtain
contact information from those with knowledge of the alien’s whereabouts.
ROUTINE USES: Information provided on this form may be used as necessary and is authorized to be used by the
routine uses published in the Alien File (A-file), Index, and National File Tracking System of Records Notice (SORN) (78
FR 69864, November 21, 2013). Further, the information on this form may be disclosed as generally permitted under the
Privacy Act of 1974, 5 U.S.C. § 552a(b).
DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the requested
information may result in ICE being unable to confirm that an alien voluntarily departed the United States or did not depart
for a valid reason. Failure to disclose the information on this form may also result in ICE being unable to locate an alien.
ICE Form G-146 (5/17)

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