Form I-356 Request for Cancellation of a Public Charge Bond

Request for Cancellation
of Public Charge Bond

USCIS
Form I-356

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0005
Expires 10/31/2021

For USCIS Use Only
Bar Code Area

Action Block

Initial Receipt

Resubmitted

Relocated
Received

Sent

Bond is

Breached
Cancelled
Continued

Comments (if needed):

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To be Completed by the Obligor and Agent/Co-Obligor's Attorney or Accredited Representative (if any).

Select this box if
Form G-28 is
attached.

Volag Number
(if any)

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

To be Completed by the Alien's Attorney or Accredited Representative (if any).

Select this box if
Form G-28 is
attached.

Volag Number
(if any)

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Obligor and Agent/Co-Obligor Information (To Be Completed by the Obligor or Agent/Co-Obligor)
Provide the following information.

Information About Obligor
1.

Name of Obligor

2.

Mailing Address

(USPS ZIP Code Lookup)

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-356 10/15/19

ZIP Code

Page 1 of 10

Part 1. Obligor and Agent/Co-Obligor Information (To Be Completed by the Obligor or Agent/Co-Obligor)
(continued)
3.

Physical Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

4.

Daytime Telephone Number

6.

Taxpayer Identification Number (TIN) (includes ITIN, EIN and SSN)

5.

ZIP Code

Email Address (if any)

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Information About Agent/Co-Obligor
7.

Name of Agent/Co-Obligor (if any-Surety Bonds only)

8.

Mailing Address

In Care Of Name (if any)

9.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Physical Address (if different from that of Obligor)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

10.

Daytime Telephone Number

12.

Taxpayer Identification Number (TIN) (includes ITIN, EIN and SSN)

13.

Power of Attorney Number

11.

ZIP Code

Email Address (if any)

Information About Bond
14.

Bond Receipt Number
►

16.

15.

Bond Amount
$

Date when Department of Homeland Security (DHS) Approved and Accepted the Bond as
Shown in Section D of the Public Charge Bond (Form I-945) (mm/dd/yyyy)

Form I-356 10/15/19

Page 2 of 10

Part 2. Obligor's or Agent/Co-Obligor's Contact Information, Certification, and Signature (To Be
Completed By the Obligor or Agent/Co-Obligor)
1.

Choose the appropriate statement and sign.
A.

The Alien Naturalized, Permanently Departed the United States, or Died
I (Name of the Obligor)

, or I (Name of the Agent/Co-Obligor)

acting on behalf of (Name of the Obligor)

,

, request that the public charge bond

executed on Form I-945 on behalf of (Name of the Alien)
born on (Alien Date of Birth (mm/dd/yyyy))

,
, and residing at

(Address of the Alien)

,

be cancelled and that (Name of the Obligor)

, and

(Name of the Agent/Co-Obligor, if any)
be released from all liabilities imposed by the conditions of the bond because the alien did not breach the bond
pursuant to 8 CFR 103.6(c)(1)(B), complied with all conditions of the bond, and either naturalized, permanently
departed the United States, or died.

B.

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,

Cancellation Following the 5th Anniversary of the Alien Becoming a Lawful Permanent Resident
I (Name of the Obligor)

, or I (Name of the Agent/Co-Obligor)

acting on behalf of (Name of the Obligor)

,

, request that the public charge bond

executed on Form I-945 on behalf of (Name of the Alien)
born on (Alien Date of Birth (mm/dd/yyyy))

,

, and residing at

(Address of the Alien)

be cancelled and that (Name of the Obligor)

,

, and the

(Name of Agent/Co-Obligor, if any)
, be released
from all liabilities imposed by the conditions of the bond, because it is past the fifth anniversary of the alien becoming
a lawful permanent resident, the alien complied with all conditions of the bond, and the alien did not breach the bond
pursuant to 8 CFR 103.6(c)(1)(B) before the fifth anniversary of becoming a lawful permanent resident.

I certify, under penalty of perjury, that all of the information in Parts 1. and 2. of this Form I-356 and any document
submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained
in, and submitted with, Parts 1. and 2. of Form I-356, and that all of this information is complete, true, and correct.

2.

Signature of Obligor

Date of Signature (mm/dd/yyyy)

3.

Signature of Agent/Co-Obligor (if any)

Date of Signature (mm/dd/yyyy)

Part 3. Information About the Alien for Whom the Public Charge Bond Was Issued (To Be Completed
By the Alien or the Alien's Executor)
1.

Alien Registration Number (A-Number) (if any)
►

3.

A-

2.

U.S. Social Security Number (SSN) (if any)
►

USCIS Online Account Number (if any)
►

Form I-356 10/15/19

Page 3 of 10

Part 3. Information About the Alien for Whom the Public Charge Bond Was Issued (To Be Completed
By the Alien or the Alien's Executor) (continued)
4.

Current Legal Name
Family Name (Last Name)

5.

Given Name (First Name)

Middle Name

Given Name (First Name)

Middle Name

Other Names You May Have Used Since Birth
Family Name (Last Name)

6.

Sex

Male

8.

Place of Birth

Female

7.

Date of Birth (mm/dd/yyyy)

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City or Town

State or Province

Country

9.

Country of Citizenship or Nationality

10.

Mailing Address

In Care Of Name (if any)

11.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Physical Address

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-356 10/15/19

Postal Code

ZIP Code

Country

Page 4 of 10

Part 4. Reason for Cancellation of the Bond
1.

I am requesting a cancellation because:
I became a U.S. Citizen (answer Item Number 2.).
I permanently departed the United States (answer Item Number 3.).
The alien is deceased and I am the executor of the alien's estate (answer Item Number 4.).
Five years have passed since I became a lawful permanent resident (answer Item Number 5.).

Answer the following questions below based on the reason for requesting a cancellation of the bond, and provide the requested
information. You should indicate whether any of the circumstances addressed in the questions have occurred since the date you
adjusted your status to that of a lawful permanent resident (for which a bond was posted on your behalf). If you are the Executor of the
deceased alien's estate, answer these questions on behalf of the deceased alien.

Became a U.S. Citizen
2.

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Have you become a United States citizen?

Yes

No. (Go to Item Number 3.)

If you answered “Yes,” please provide the information requested.
A.

B.

D.

Certificate of Naturalization Number or Citizenship Certificate Number (if applicable)

Date of Naturalization or Acquired Citizenship
(mm/dd/yyyy)

C.

U.S. Passport Number (if applicable)

Date When Passport Issued (if applicable)
(mm/dd/yyyy)

Permanently Departed the United States
3.

Have you permanently departed the United States? Please provide documentation.
Yes

No, I have not permanently departed the United States. (Go to Item Number 4.)

If you answered “Yes,” please provide the following information (as applicable) in Items. A. - E.
A.

C.

Date you left the United States
(mm/dd/yyyy)

B.

Place of Departure/Removal, Exclusion, or Disposition

Date When Record of Abandonment of Lawful Permanent Resident
Status (Form I-407) was filed (mm/dd/yyyy)

D.

Place Where Form I-407 (USCIS International Office, U.S. Embassy/Consular Section/ Port of Entry) Was Filed

E.

Date of the Removal, Exclusion, Deportation, or Voluntary Departure Order (mm/dd/yyyy)

Form I-356 10/15/19

Page 5 of 10

Part 4. Reason for Cancellation of the Bond (continued)
Deceased
4.

Has the alien on whose behalf a bond has been issued died?

Yes

No. (Go to Item Number 5.)

If you answered “No,” go to Item Number 5. If you answered “Yes,” please provide the information in Items A. - B. about the
alien's death and attach a certified copy of the alien's death certificate:
A.

Date of Alien's Death (mm/dd/yyyy)

B.

Death Certificate Number (please attach an official copy of the death certificate)

Information about the person completing Item Number 4. on behalf of the deceased alien (Please attach a certified copy that
establishes your legal authority to act on behalf of the alien's estate):
Full Name

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Family Name (Last Name)

Given Name (First Name)

Middle Name

Physical Address

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Mailing Address

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Daytime Telephone Number

Postal Code

ZIP Code

Country

Email Address (if any)

Relationship to Deceased

Form I-356 10/15/19

Page 6 of 10

Part 4. Reason for Cancellation of the Bond (continued)
Five Years After Becoming a Lawful Permanent Resident
5.

Have you been a lawful permanent resident for at least five years?

Yes

No

If you answered “Yes,” please provide the information about when you became a lawful permanent resident below.
Date When You Became a Lawful Permanent Resident (mm/dd/yyyy)

Receipt of Public Benefits
6.

Has the alien received any means-tested public benefit before the event that forms the basis for the
cancellation request (the fifth anniversary of becoming a lawful permanent resident, the date the alien
became a United States citizen, , the date the alien permanently departing the United States, or the date of the
alien’s death, whichever is applicable)?

Yes

No

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If you answered “Yes,” please provide information about which means-tested public benefit(s) you received and when,
including the source that provided the benefit (the Federal, or a specific State, territorial, tribal, or local government or
government agency).

Part 5. Alien's (or Alien Executor's) Contact Information, Certification, and Signature
Alien's (or the Alien's Executor's) Contact Information
1.

Daytime Telephone Number

3.

Email Address (if any)

2.

Mobile Telephone Number (if any)

Federal Agency Disclosure and Authorizations
I

,

authorize, as applicable, the Social Security Administration (SSA) to verify my/the alien's Social Security number (to match my name,
Social Security number, and date of birth with information in SSA records and provide the results of the match) to USCIS. I (the alien/
the alien's executor) authorize SSA to provide explanatory information to USCIS as necessary.
I

,

as applicable, understand that the information released by records custodians and sources of information is for official use by the
federal government, that the government will use it only to review my/the alien's eligibility for immigration benefits and to enforce
immigration laws, and that the government may disclose the information only as authorized by law.

Alien's (or Alien's Executor's) Certification and Signature
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine whether the bond should be cancelled.
I furthermore authorize release of information contained in this form, in supporting documents, and in my/the alien's USCIS records,
to other entities and persons where necessary for the administration and enforcement of U.S. immigration law.
4.

Alien's (or Alien's Executor's) Signature

Form I-356 10/15/19

Date of Signature (mm/dd/yyyy)

Page 7 of 10

Part 6. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

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Interpreter's Certification

, and I have
I certify, under penalty of perjury, that I am fluent in English and
interpreted every question on the Form I-356 and Instructions and interpreted the alien or the alien's executor’s answers to the
questions in that language, and the alien or the alien's executor informed me that he or she understood every instruction, question, and
answer on the Form I-356.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 7. Contact Information, Declaration, and Signature of the Person Preparing the Alien's Parts of
Form I-356, if Other Than the Alien (or the Alien's Executor)
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

Form I-356 10/15/19

4.

Preparer's Mobile Telephone Number (if any)

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Part 7. Contact Information, Declaration, and Signature of the Person Preparing the Alien's Parts of
Form I-356, if Other Than the Alien (or the Alien's Executor) (continued)
Preparer's Certification and Signature
I certify, under penalty of perjury, that I prepared this request for the alien or the alien's executor at their request and with express
consent and that all of the responses and information contained in and submitted with the request are complete, true, and correct and
reflects only information provided by the alien or the alien's executor. The alien or the alien's executor reviewed the responses and
information and informed me that they understand the responses and information in or submitted with the request.
6.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

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Form I-356 10/15/19

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Part 8. Additional Information
If you need extra space to provide any additional information within this request, use the space below. If you need more space than
what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of paper. Please
type or print the alien's name and A-Number (if any), the obligor's name, and bond receipt number, at the top of each additional sheet;
indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A.

Page Number

B.

Given Name (First Name)

Part Number

C.

Middle Name

Item Number

D.

4.

A.

D.

5.

A.

D.

6.

A.

D.

7.

A.

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Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

Page Number

B.

Part Number

C.

Item Number

D.

Form I-356 10/15/19

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