Form EOIR-42A

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for Certain Permanent Residents

ADVICE TO APPLICANT

PLEASE READ CAREFULLY. FEES WILL NOT BE RETURNED.

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

1. You have been a permanent resident for at least five (5) years;

2. You have at least seven (7) years continuous residence in the United States after having been lawfully admitted in any status prior to service of the Notice to Appear, or prior to committing

a criminal or related offense referred to in sections 212(a)(2) and 237(1)(2) of the INA, or prior to committing a security or related offense referred to in section 237(1)(4) of the INA; and

3. You have not been convicted of an aggravated felony.

NOTE: 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 residence 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.

2. Permanent Resident Aliens NOT Eligible for Cancellation of Removal: You are not eligible to have your removal cancelled under section 240A(a) of the INA if you:

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

2. 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 a 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;

3. 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;

4. 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;

5. 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

6. 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.

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for Certain Permanent Residents

3. How Permanent Resident Aliens Can 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-42A 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 7 of this application, if applicable, and you must file your application with the appropriate

Immigration Court. Please read the following instructions carefully before completing your application.

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for Certain Permanent Residents

INSTRUCTIONS

1. PREPARATION OF APPLICATION.

To apply for cancellation of removal as a permanent resident alien under section 240A(a) of the Immigration and Nationality Act (INA), you must fully and accurately answer all questions on the attached Form EOIR-42A. You must also comply with all of the instructions on 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-42A.

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 permanent resident aliens under section 240A(a) 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 relief

(see "SUPPORTING DOCUMENTS" below).

3. SUPPORTING DOCUMENTS.

You should submit with your application copies of any documents which the Department of Homeland Security (DHS), formerly the Immigration and Naturalization Service, issued to you. You should also submit all documents related to your criminal history, including all conviction records. The Immigration Judge may require you to submit additional records relating to your request for cancellation of removal.

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 infor- mation. You will be given instructions on how to complete this requirement. You will be notified in writing of the loca- tion 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 fur- nish all the required information. Failure to comply with this requirement may result in a delay in your appointment 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.

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for Certain Permanent Residents

6. FEES.

Before you file your Form EOIR-42A with the Immigration Court, you must pay the required $100 filing fee and the biometrics fee to the 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-42A. 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-42A 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." Personal checks are accepted subject to collectibility. An uncollectible check will render the application and any docu- ments issued pursuant thereto 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.

7. SERVING & FILING YOUR APPLICATION.

   1. 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.

   2. 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-42A, Application for Cancellation of Removal, with all supporting docu- ments and additional sheets;

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

      • the original Biographical Information Form G-325A.

Note: Electronic filers are not required to serve the opposing party if the opposing party is participating in ECAS.EOIR's ECAS system will provide an electronic service notification to participating parties.

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

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

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

• a copy of the Biographical Information Form G-325A; and

• a completed certificate showing service of these documents (See Part 10 of the Application on page 7) on the ICE Assistant Chief Counsel or affirmation that the documents were electronically filed through ECAS, 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.

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for Certain Permanent Residents

8. PENALTIES.

You must answer all questions on Form EOIR-42A 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 retain your permanent resident 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 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. 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 deter- mined you have violated the prohibition against document fraud and a 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.

9. 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 under-stood, 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 bur-den, 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.

U.S. Department of Justice

Executive Office for Immigration Review

OMB#ll25-0001

Application for Cancellation of Removal for Certain Permanent Residents

Street and Number - Apt. or Room # - City or Town - State - Zip Code	Resided From: (Month, Day, Year)	Resided To: (Month, Day, Year)
		PRESENT

Fee Stamp (Official Use Only)

PLEASE READ ADVICE AND INSTRUCTIONS BEFORE FILLING IN FORM

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)		4) Birth Place: (City and Country)
5) Date of Birth: (Month, Day, Year)	Gender: Male ❏ Female	7) Height:	8) Hair Color:		9) Eye Color:
10) Current Nationality and Citizenship:	11) Social Security Number:	12) Home Phone Number: ( )		13) Work Phone Number: ( )
14) I currently reside at: Apt. number and/or in care of Number and Street City or Town State Zip Code		15) I have been known by these additional name(s):
16) I have resided in the following locations in the United States: (List PRESENT ADDRESS FIRST, and work back in time for at least 7 years.)
PART 2 - INFORMATION ABOUT THIS APPLICATION
17) I, the undersigned, hereby request that my removal be cancelled under the provisions of section 240A(a) of the Immigration and Nationality Act (INA). I believe that I am eligible for this relief because I have been a lawful permanent resident alien for 5 or more years, have 7 years of continuous residence in the United States, and have not been convicted of an aggravated felony. I was admitted as or adjusted to the status of an alien lawfully admitted for permanent residence on (Date) at . (Place)

PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES
18) My first arrival into the United States was under the name of: (Last, First, Middle)					19) My first arrival to the United States was on: (Month, Day, Year)
20) Place or port of first arrival: (Place or Port, City, and State)
21) I: ❏ was inspected and admitted. I entered using my Lawful Permanent Resident card which is valid until . Category on Lawful Permanent Resident card (Month, Day, Year) I entered using a visa which is valid until . was not inspected and admitted. (Specify Type of Visa) (Month, Day, Year) I entered without documents. Explain: . I entered without inspection. Explain: . Other. Explain: .
22) I applied on for additional time to stay and it was ❏ granted on (Month, Day, Year) (Month, Day, Year) and valid until , or ❏ denied on . (Month, Day, Year) (Month, Day, Year)
23) 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 this box:
1	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			Inspected and Admitted? Yes ❏ No
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			Inspected and Admitted? Yes ❏ No
24) Have you ever departed the United States: a) under an order of deportation, exclusion, or removal?. ❏ Yes ❏ No b) pursuant to a grant of voluntary departure?. ❏ Yes ❏ No
PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued on page 3)
25) I am not married: ❏ I am married: ❏		26) If married, the name of my spouse is: (Last, First, Middle)				27) My spouse’s name before marriage was:
28) The marriage took place in: (City and Country)				29) Date of marriage: (Month, Day, Year)
30) My spouse currently resides at: Apt. number and/or in care of Number and Street City or Town State/Country Zip Code				31) Place and date of birth of my spouse: (City & Country; Month, Day, Year)
				32) My spouse is a citizen of: (Country)
33) If your spouse is other than a native born United States citizen, answer the following: He/she arrived in the United States at: (Place or Port, City and State) . He/she arrived in the United States on: (Month, Day, Year) . His/her alien registration number(s) is: A# . He/she was naturalized on: (Month, Day, Year) at . (City and State)
34) My spouse ❏ - 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)
	$
	$
	$

PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued)
35) 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.)
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 result of a separation and/or divorce? ❏ - Yes ❏ - No
PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS
37) Since my 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
	$
	$
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 Jointly Owned With Spouse Cash, Stocks, and Bonds................................ $ Cash, Stocks, and Bonds. $ Real Estate...................................................... $ Real Estate. $ Auto (dollar value minus amount owed)....... $ Auto (dollar value minus amount owed) $ Other (describe on line below)....................... $ Other (describe on line below). $ TOTAL $ TOTAL $
40) I ❏ - have ❏ - have not received public or private relief or assistance (e.g., Welfare, Unemployment Benefits, Medicaid, TANF, AFDC, 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 total 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:

Name of 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:

Name of 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:

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:

43) If your application is denied, would your spouse and all of your children accompany you to your:

If you answered “No” to any of the

^{Country of Birth - ❏ Yes ❏ No} responses, please explain:

Country of Nationality - ❏ Yes ❏ No

Country of Last Residence - ❏ Yes ❏ No

44) 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, 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:

45) 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 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)		Immigration Status of Child
A#:
Estimated Total of Assets: $ Estimated Average Weekly Earnings: $
A#:
Estimated Total of Assets: $ Estimated Average Weekly Earnings: $
A#:
Estimated Total of Assets: $ Estimated Average Weekly Earnings: $

Name: (Last, First, Middle) Alien Registration Number:		Citizen of What Country: Birth Date: (Month, Day, Year)	Relationship to Me: Birth Place: (City and Country)		Immigration Status of Listed Relative
A#:
Complete Address of Current Residence, if Living:
A#:
Complete Address of Current Residence, if Living:

PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6)

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

47) I ❏ - have ❏ - have not been admitted as, or after arrival in the United States acquired the status of, an exchange alien.

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

49) 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. You are required to submit documentation of any such occurrences.)

50) Have you ever served in the Armed Forces of the United States? ❏ - Yes ❏ - No. If “Yes” please state branch (Army, Navy, etc.) and

service number: Place of entry on duty: (City and State) Date of entry on duty: (Month, Day, Year) 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) .

51. 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

52) Have you ever deserted from the military or naval forces of the United States while the United States was at war? ❏ Yes ❏ No

53) If male, did you register under the Military Selective Service Act or any applicable previous Selective Service (Draft) Laws? ❏ Yes ❏ No

If “Yes,” please give date, Selective Service number, local draft board number, and your last draft classification:

54) Were you ever exempted from service because of conscientious objection, alienage, or any other reason? ❏ Yes ❏ No

55) 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 16^th 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	Location of Organization	Nature of Organization	Member From: (Month, Day, Year)	Member To: (Month, Day, Year)

PART 7 - MISCELLANEOUS INFORMATION (Continued)

56. Have you ever:

    • Yes ❏ No been ordered deported, excluded, or removed?

    • Yes ❏ No overstayed a grant of voluntary departure from an Immigration Judge or the Department of Homeland Security

(DHS), formerly the Immigration and Naturalization Service (INS)?

• Yes ❏ No failed to appear for deportation or removal?

57. Have you ever been:

    • Yes ❏ No a habitual drunkard?

    • Yes ❏ No one whose income is derived principally from illegal gambling?

    • Yes ❏ No one who has given false testimony for the purpose of obtaining immigration benefits?

    • Yes ❏ No one who has engaged in prostitution or unlawful commercialized vice?

    • Yes ❏ No involved in a serious criminal offense and asserted immunity from prosecution?

    • Yes ❏ No a polygamist?

    • Yes ❏ No one who brought in or attempted to bring in another to the United States illegally?

    • Yes ❏ No a trafficker of a 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)?

    • Yes ❏ No inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?

    • Yes ❏ No 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?

    • Yes ❏ No a person previously granted relief under 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:

58. Name of School, Type of School, Degree Earned / Date (if any), Location (City/Country), Attended From (MM/YY) To (MM/YY)

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

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

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

___________________________________________________ ___________________________________________________

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-42A may subject me to civil penalties under 8 U.S.C. § 1324c.
Signature of Preparer:		Print Name:	Date:
Daytime Telephone #: ( )	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-42A was: ❏ - delivered in person ❏ - mailed first class, postage prepaid on to the Assistant Chief Counsel for the DHS (U.S. Immigration and Customs Enforcement-ICE) (Month, Day, Year) at (Number and Street, City, State, Zip Code) ❏ No service needed. I electronically filed this document, and the opposing party is participating in ECAS. Signature of Applicant (or Attorney or Representative)

Form EOIR-42A

Revised Jan 2022