Form I-407 Record of Abandonment of Lawful Permanent Resident Statu

Record of Abandonment of
Lawful Permanent Resident Status
Department of Homeland Security
U.S. Citizenship and Immigration Services

Part 1. Information About the Alien
1.

Alien Registration Number (A-Number)
► A-

2.

USCIS Online Account Number (if any)
►

OMB No. 1615-0130
Expires 02/28/2017

State the reasons for abandoning lawful permanent
resident status.

DRAFT
Not for
Production
03/23/2017
(Ext+PAS)

Your Full Legal Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)

10.

USCIS
Form I-407

Documents Surrendered and Location of
Submission

11.a. Form I-551 (Permanent Resident Card)

Yes

No

11.b. If the Form I-551 is not surrendered, select the reason why.
Lost
Stolen
Mutilated
Other

3.c. Middle Name

Other Information

11.c. List other documents surrendered (if any).

4.

Date of Birth (mm/dd/yyyy)

5.

Country of Birth

12.a.

I am submitting Form I-407 outside of the United
States in-person.

6.

Country of Citizenship or Nationality

12.b.

I am submitting Form I-407 outside of the United
States by mail.

7.

Date of Last Departure from the United States

12.c.

I am submitting Form I-407 at a U.S. Port of Entry.

(mm/dd/yyyy)

Certification

Mailing Address Abroad
8.a.

In Care Of Name (if applicable)

8.b. Street Number
and Name
8.c.

Apt.

Ste.

8.d. City or Town

Flr.

I knowingly, willingly, and affirmatively declare that I have no
intention of residing permanently in the United States, and that
by signing and submitting this form, I intend to record the fact
that I have knowingly and willingly abandoned my lawful
permanent resident status in the United States. I have been
informed of, and I understand my rights to a hearing before an
immigration judge about whether I have abandoned my lawful
permanent resident status in the United States. By signing and
submitting this form, I knowingly, willingly, and affirmatively
waive my rights to such a hearing.

8.e. Province or State

13.a. Signature of Alien

8.f.

13.b. Date of Signature (mm/dd/yyyy)

Postal Code

8.g. Country

9.

E-mail Address (if any)

Form I-407 02/26/15 N

NOTE: Signing this form is voluntary. U.S. law does not
require you to complete, sign, or submit this form. You may
request a hearing before an immigration judge if you disagree
with a DHS allegation that you have abandoned your lawful
permanent residence.

Page 1 of 2

Part 1. Information About the Alien (continued)
For Consent of Parents, Custodial Parents, or Legal
Guardian to Submit Form I-407 for Minors 17 Years
of Age or Younger

The alien has informed me that he or she understands each and
every instruction and question on the form, as well as the
answer to each and every question.
1.a. Signature of Interpreter (if applicable)

As the parents or guardian of the alien minor who is identified
in Part 1. of this form, I/we consent to the alien minor's
submission of this form.

1.b. Full Name of Interpreter

14.a. Signature of Parents, Custodial Parents, or Legal Guardian

1.c. Date of Signature (mm/dd/yyyy)

DRAFT
Not for
Production
03/23/2017
(Ext+PAS)

Part 3. For Government Use Only

14.b. Name of Parents, Custodial Parents, or Legal Guardian

14.c. Date of Signature (mm/dd/yyyy)

Instructions to officer: Select Item Number 1. if you
interviewed the alien. If you did not, select Item Number 2.
and state the basis for your conclusion that the alien may have
abandoned lawful permanent resident status. Sign the form and
provide other information requested.

1.

I certify that I personally interviewed the alien who is
identified in Part 1., who has signed this Form I-407,
and that I advised the alien of the hearing rights
specified in the Instructions. The alien stated he or
she fully understands the effect of signing this Form
I-407. I further certify that, if an interpreter was
used, I confirmed that the alien understood the
interpreter.

2.

I certify that I was not able to interview the alien who
is identified in Part 1. of this Form I-407. My basis
for concluding that the alien may have abandoned
lawful permanent resident status is:

If signed by only one parent, custodian, or legal guardian,
indicate evidence to show sole parental, custodial, or legal
guardianship responsibility.
14.d. Check all that apply:

Death of other parent

Termination of other parent's rights

Award of sole legal custody

Appointment as guardian

3.

Part 2. Certification and Signature of the
Interpreter

A copy of the signed Form I-407 was provided to the alien.
Yes
No

DHS/Consular Officer Information

4.a. Name of DHS/Consular Officer

Interpreter Certification
I certify that:
I am fluent in English and
(write the other language in the box provided above).
I further certify that I have read each and every question and
instruction on this form, as well as the answer to each and every
question on this form, in the language provided above; and

4.b. Signature of DHS/Consular Officer

4.c. Title of DHS/Consular Officer

4.d. Name of DHS Component, if signed by a DHS officer

4.e. Date of Signature (mm/dd/yyyy)
Form I-407 02/26/15 N

Page 2 of 2