Application for Cancellation of Removal and Adjustment of Status for Certain Nonpermanent Residents

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U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

ADVICE TO APPLICANT
PLEASE READ CAREFULLY. FEES WILL NOT BE RETURNED.

Aliens Eligible for Cancellation of Removal
You may be eligible to have your removal cancelled under section 240A(b) of the Immigration
and Nationality Act (INA). To qualify for this benefit, you must establish in a hearing before an
Immigration Judge that you have satisfied one or both of the following sets of requirements:
If Battered or Subjected to Extreme Cruelty By
Your United States Citizen or Law Permanent
Resident Spouse or Parent
1. You have been battered or subjected to
extreme cruelty by your United States citizen
or lawful permanent resident spouse or
parent, or you are the parent of a child of a
United States citizen or lawful permanent
resident and the child has been battered or
subjected to extreme cruelty by such United
States citizen or lawful permanent resident
parent;
2. You have maintained continuous physical
presence in the United States for at least 3
years immediately preceding the date of the
decision on your application;
3. You have been a person of good moral
character as defined in section 101(f) of the
INA for at least 3 years immediately
preceding the date of the decision on your
application (Note: Acts or convictions that
qualify for an exemption under section
240A(b)(2)(C) of the INA do not prevent you
from showing good moral character);
4. You are not inadmissible under section
212(a)(2) or 212(a)(3) of the INA, you are
not deportable under section 237(a)(1)(G) or
237(a)(2)-(4) of the INA, and you have not
been convicted of an aggravated felony;
5. Your removal would result in extreme
hardship to you, your child, or your parent;
and
6. You are deserving of a favorable exercise of
discretion on your application.

All Other Applicants
1. You have maintained continuous
physical presence in the United States
for at least 10 years immediately prior
to the service of the Notice to Appear;
2. You have been a person of good moral
character as defined in section 101(f) of
the INA for at least 10 years
immediately preceding the date of the
decision on your application;
3. You have not been convicted of an
offense described under sections
212(a)(2), 237(a)(2), or 237(a)(3) of the
INA;
4. Your removal would result in
exceptional and extremely unusual
hardship to your United States citizen or
lawful permanent resident spouse,
parent, or child (unmarried and under
age 21); and
5. You are deserving of a favorable
exercise of discretion on your
application.

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

NOTE: If you have served in 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 physical presence 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.

Aliens NOT Eligible for Cancellation of Removal
You are not eligible for cancellation of removal under section 240A(b)(1) 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 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 Immigration Responsibility Act of 1996, or whose removal has
previously been cancelled under section 240A of the INA.

How to Apply for Cancellation of Removal
If you believe that you have met all of the requirements for cancellation of removal, you must
answer all of the questions on the attached Form EOIR-42B fully and accurately. You must pay
the form filing fee and comply with the Department of Homeland Security (DHS) instructions
for providing biometric information at an Application Support Center (ASC) operated by U.S.
Citizenship and Immigration Services (USCIS). You must also serve a copy of your application
on the Counsel for the DHS, U.S. Immigration and Customs Enforcement (ICE) as required in
Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

the Proof of Service section of this form, if applicable, and you must file your application with
the appropriate Immigration Court. Please read the following instructions carefully before
completing your application.

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

INSTRUCTIONS
Preparation of the Application
To apply for cancellation of removal as a nonpermanent resident alien under section 240A(b) of
the Immigration and Nationality Act (INA), you must fully and accurately answer all questions
on the attached Form EOIR-42B. You must also comply with all of the instructions on this form.
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. 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 (A-number), print your name, and sign, date, and securely
attach each additional sheet to the Form EOIR-42B using paper clips or binder clips.

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 nonpermanent resident aliens under section 240A(b) 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 section below).

Supporting Documents
You should submit documentary evidence to show that you have maintained continuous physical
presence in the United States for the required period. Documents which may show evidence of
your physical presence in the United States include, but are not limited to, bank records, leases,
deeds, licenses, receipts, letters, birth records, church records, school records, employment
records, and evidence of tax payments.

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

You should submit documents which help to show that you are, and have been, a person of good
moral character for at least the past ten years (or three years if applying based on having been
battered or subjected to extreme cruelty). You should submit police records from each
jurisdiction in which you resided during such period. To show good moral character, it is
recommended that you submit the affidavits of witnesses attesting to your good moral character,
preferably citizens of the United States, and if you are employed, your employer. The affidavit
from your employer should include information regarding the nature and duration of your
employment and your earnings.
You should submit official certificates to establish your relationship to those you claim would
suffer hardship by your removal, and if such persons are citizens of the United States or lawful
permanent residents, evidence of their citizenship or lawful permanent resident status.
Documentary evidence of such relationships may include, but is not limited to, birth records,
marriage certificates, proof of divorce or termination of prior marriages, and death certificates.
You should also submit with your application copies of any documents which the Department of
Homeland Security (DHS), formerly the Immigration and Naturalization Service (INS), issued to
you. You should also submit all documents which reflect payment of taxes, your criminal history,
including all conviction records, and payment of child support during your physical presence in
the United States. 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.

Required Biometrics and Other Biographical Information
Each applicant 14 years of age or older must also comply with the requirement to supply
biometrics and other biographical information. The DHS will provide instructions on how and
where to complete the biometrics requirement. These instructions are also available on the DHS
website (https://www.uscis.gov/laws-and-policy/other-resources/immigration-benefits-in-eoirproceedings). Failure to comply with DHS instructions may result in a delay in your biometric
services appointment and/or the Immigration Court may deem your application for cancellation
of removal abandoned and deny it. For more information about preparing for the DHS biometrics
services appointment, please consult the DHS website (https://www.uscis.gov/forms/filingguidance/preparing-for-your-biometric-services-appointment).

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

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.

Fees
Before you file this form with the Immigration Court, you must pay the required filing fee to
EOIR. Current filing fee amounts are listed on the EOIR website
(https://www.justice.gov/eoir/eoir-forms). The filing fee must be paid electronically through the
EOIR Payment Portal (https://epay.eoir.justice.gov/index) with a debit or credit card, PayPal
account, Amazon Pay, or a checking or savings account (ACH). 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. Payments by cash, check,
money order, or cashier’s check are not accepted.
To pay electronically through the EOIR Payment Portal, you will need to enter the A-number
associated with the case in the Immigration Court and select the filing type. This information will
be printed on your receipt once payment is complete. You will be redirected to the U.S. Treasury
Pay.gov website to complete payment. Once your transaction is completed, you will be
redirected back to the EOIR Payment Portal to print your EOIR fee payment receipt. You must
submit your EOIR fee payment receipt with your filing. Filings will not be accepted without
proof of payment. Your filing may be rejected if you fail to submit an EOIR fee payment receipt
or if your electronic payment is uncollectible. If you are unable to pay the filing fee, you may ask
the Immigration Judge to permit you to file your Form EOIR-42B without a fee by filing a Fee
Waiver Request (Form EOIR-26A).

Serving and Filing Your Application
You must comply with the DHS USCIS instructions for providing biometrics and other
biographical information. Retain your USCIS ASC biometrics confirmation document as proof
that your biometrics were taken and bring this proof to your future Immigration Court hearings.
You must file the following documents with the appropriate Immigration Court:
1. The original completed Form EOIR-42B with all supporting documents and any
continuation sheets; and
Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

2. Proof of payment of the Form EOIR-42A filing fee or a completed Fee Waiver Request
(Form EOIR-26A).
Any documents you file with the Immigration Court must be served on the opposing party. Serve
your filing on the Counsel for DHS, U.S. Immigration and Customs Enforcement (ICE). Your
application will be rejected if the Proof of Service section on the last page of Form EOIR-42A is
not completed.
Note: Electronic filers are not required to serve the opposing party if the opposing party is
participating in ECAS; the ECAS system will provide an electronic service notification to
participating parties. However, electronic filers must still sign and complete the Proof of Service
section.

Penalties
You must answer all questions on the Form EOIR-42B truthfully and accurately, and you must
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 adjust your 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. § 1546 and/or to civil penalties under 8 U.S.C. § 1324c if you submit your application
knowing that the application, or any supporting document, contains any false statement with
respect to a material fact. If convicted, you could be fined up to $250,000, imprisoned for up to
10 years, or both. See 18 U.S.C. §§ 1546(a), 3559(a)(4), 3571(b)(3). If it is determined that 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. § 1324c, relating to civil penalties for document fraud, you
will be removable from the United States.

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

U.S. Department of Justice
Executive Office for Immigration Review

OMB #1125-0001
Application for Cancellation of Removal
and Adjustment of Status for Certain
Nonpermanent Residents

Paperwork Reduction Act Notice
Under the Paperwork Reduction Act (PRA), 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 be easily understood, 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
estimated at an average of 5 hours, 50 minutes per application, 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. 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 burden, 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, or email
[email protected].

Privacy Act Notice
This collection of information is authorized by Section 240A(b) of the INA (8 U.S.C. §
1229b(b)) in order to adjudicate an applicant’s request for cancellation of removal and
adjustment of status for certain nonpermanent residents. The collected information is mandatory
and required to decide whether to permit the applicant to remain in the United States. Failure to
provide the requested information would prevent the applicant from establishing their eligibility
for cancellation of removal and adjustment of status. EOIR may share this information with
others in accordance with approved routine uses as described in the following system of records
notices (SORNs), or their successors: JUSTICE/EOIR-001, Adjudication and Appeal Records of
the Office of the Chief Immigration and Board of Immigration Appeals, 90 Fed. Reg. 42265
(Aug. 29, 2025). This SORN can be found on the Department of Justice website
(https://www.justice.gov/opcl/doj-systems-records#).

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

OMB#1125-0001

Application for Cancellation of Removal and Adjustment
of Status for Certain Nonpermanent Residents

U.S. Department of Justice
Executive Office for Immigration Review

PLEASE READ ADVICE AND INSTRUCTIONS
BEFORE FILLING IN FORM

Fee Stamp (Official Use Only)

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 andCountry)

5) Date of Birth: (Month, Day, Year)

6) Sex:

10) Current Nationality and Citizenship:

11) Social Security Number:

❑ Male

❏ Female

7) Height:

8) Hair Color:

12) Home Phone Number:

9) Eye Color:

13) Work Phone Number:

15) I have been known by these additional name(s):

14) I currently reside at:

16) I have resided in the following locations in the United States: (List PRESENT ADDRESS FIRST, and work back in time for at least 10
years.)
Street and Number - Apt. or Room # - City or Town - State - Zip Code

Resided From:

Resided To:

(Month, Day, Year)

(Month, Day, Year)

PRESENT

PART 2 - INFORMATION ABOUT THIS APPLICATION
17) I, the undersigned, hereby request that my removal be cancelled under the provisions of section 240A(b) of the Immigration and Nationality
Act (INA). I believe that I am eligible for cancellation of removal because: (Check all that apply.)

❑ My removal would result in exceptional and extremely unusual hardship to my:
LAWFUL PERMANENT
RESIDENT

UNITED STATES
CITIZEN

spouse, who is a
father, who is a
mother, who is a
child/children, who is/are a
___ I , or my child, have been battered or subject to extreme cruelty by a United States citizen or lawful permanent
resident spouse or parent.
With the exception of absences described in question #23, I have resided in the United States since:

Please continue answers on a separate sheet as needed.
(1)

(Month, Day, Year)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES
18) I first arrived in the United States under the name of: (Last, First, Middle)

19) I first arrived in the United States 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 a
❑

visa which is valid until

(Specify Type of Visa)

.

(Month, Day, Year)

❑ was not inspected and admitted.
❑ I entered without documents. Explain:
❑ I entered without inspection. Explain:

.

❑ Other. Explain:

.

22) I applied on

(Month, Day, Year)

and valid until

(Month, Day, Year)

.

for additional time to stay and it was ❏ granted on
, 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

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?

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?

24) Have you ever departed the United States:

❑ Yes ❏ No

❑ Yes ❏ No
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:

31) Place and date of birth of my spouse: (City & Country; Month, Day, Year)

Apt. number and/or in care of

32) My spouse is a citizen of: (Country)

Number and Street
City or Town

State/Country

Zip Code

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#

.
at

He/she was naturalized on: (Month, Day, Year)

.

(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)

$
$
$
Please continue answers on a separate sheet as needed.
(2)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

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.)
Name of prior spouse: (Last, First, Middle)

Place marriage ended:

Date marriage began:
Date marriage ended:

(City and Country)

Description or manner of how marriage was
terminated or ended:

36) My present spouse ❏ - has ❏ - has not been previously married: (If previously married, list the names 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.)
Name of prior spouse: (Last, First, Middle)

Place marriage ended:

Date marriage began:
Date marriage ended:

(City and Country)

Description or manner of how marriage was
terminated or ended:

37) 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
38) 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:

Employed To:

(Month, Day, Year)

(Month, Day, Year)

PRESENT

$
$
$
39) If self-employed, describe the nature of the business, the name of the business, its address, and net income derived therefrom:

40) My assets (and if married, my spouse’s assets) in the United States and other countries, not including clothing and household necessities, are:
Self
Cash, Stocks, and Bonds................................ $
Real Estate...................................................... $
Auto (dollar value minus amount owed)....... $
Other (describe on line below)....................... $
TOTAL $

Jointly Owned With Spouse
Cash, Stocks, and Bonds. ...............................$
Real Estate...................................................... $
Auto (dollar value minus amount owed)........$
Other (describe on line below). ...................... $
TOTAL $

41) 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:

42) Please list each of the years in which you have filed an income tax return with the Internal Revenue Service:

Please continue answers on a separate sheet as needed.
(3)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued on page 5)
43) 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:
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: $

44) If your application is denied, would your spouse and all of your children accompany you to your:
Country of Birth -

❏ Yes ❏ No

Country of Nationality -

❏ Yes ❏ No

If you answered “No” to any of the
responses, please explain:

Country of Last Residence - ❏ Yes ❏ No

45) 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:

46) 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: (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:

Please continue answers on a separate sheet as needed.
(4)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued)
IF THIS APPLICATION IS BASED ON HARDSHIP TO A PARENT OR PARENTS, QUESTIONS 47-50 MUST BE ANSWERED.
47) If your parent is not a citizen of the United States, give the date and place of arrival in the United States including full details as to the date,
manner, and terms of admission into the United States:

48) My father ❏ - 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)

$
49) My mother ❏ - is ❏ - is not employed. If employed, please give salary and the name and address of place(s) of employment.
Full Name and Address of Employer

Earnings Per Week
(Approximate)

$
50) My parent’s assets in the United States and other countries not including clothing and household necessities are:
Assets of father consist of the following:
Assets of mother consist of the following:
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 $

PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6)
51) I ❏ - have ❏ - have not entered the United States as a crewman after June 30, 1964.
52) I ❏ - have ❏ - have not been admitted as, or after arrival in the United States acquired the status of, an exchange alien.
53) I ❏ - have ❏ - have not submitted address reports as required by section 265 of the Immigration and Nationality Act.
54) I ❏ - have ❏ - have never (either in the United States or in any foreign country) been arrested, cited, charged, 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.)

55) 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)

56) 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
Please continue answers on a separate sheet as needed.
(5)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

PART 7 - MISCELLANEOUS INFORMATION (Continued)
57) Have you ever deserted from the military or naval forces of the United States while the United States was at war?

❏ Yes ❏ No

58) If male, did you register under the Military Selective Service Act or any applicable previous Selective Service (Draft) Laws?
If “Yes,” please give date, Selective Service number, local draft board number, and your last draft classification:

❏ Yes ❏ No

59) Were you ever exempted from service because of conscientious objection, alienage, or any other reason?

❏ Yes ❏ No

60) Please list your present or past membership in or affiliation with every organization, association, fund, foundation, political party, club, society,
or similar group in the United States or any other place since your 16th 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

61) Have you ever:
Yes

No

Location of Organization

Nature of Organization

Member From:
(Month, Day, Year)

Member To:

(Month, Day, Year)

been ordered deported, excluded, or removed?
overstayed a grant of voluntary departure from an Immigration Judge or the Department of Homeland Security (DHS),
formerly the Immigration and Naturalization Service (INS)?
failed to appear for removal or deportation?

62) Have you ever been:
Yes No
a habitual drunkard?
one whose income is derived principally from illegal gambling?
one who has given false testimony for the purpose of obtaining immigration benefits?
one who has engaged in prostitution or unlawful commercialized vice?
one who has committed, ordered, incited, assisted, or otherwise participated in genocide, any act of torture, extrajudicial
killing, or a particularly severe violation of religious freedom?
a polygamist?
one who knowingly encouraged, induced, assisted, abetted, or aided any other alien to illegally enter or try to enter the U.S.?
except as already disclosed in response to Question 54, one who has either (1) committed any crime (even if you were not
arrested, cited, charged, or convicted) or (2) committed any offense or act referred to in section 212(a)(2) of the INA?
inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?
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?
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:

Please continue answers on a separate sheet as needed.
(6)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

PART 7 - MISCELLANEOUS INFORMATION (Continued)
63) Are you the beneficiary of an approved visa petition? ❏ Yes ❏ No
If yes, can you arrange a trip outside the United States to obtain an immigrant visa? ❏ Yes ❏ No If no, please explain:

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

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

Please continue answers on a separate sheet as needed.
(7)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD

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-42B may subject me to
civil penalties under 8 U.S.C. § 1324(c).

Signature of Preparer:

Print Name:

Daytime Telephone #:

Date:

Address of Preparer: (Number and Street, City, State, Zip Code)

PART 9 - SIGNATURE OF APPLICANT
NOTICE: YOU MUST SIGN BELOW BEFORE YOU FILE THIS APPLICATION.
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.

(Signature of Applicant or Parent or Guardian)

Print Name

Date: (Month, Day, Year)

PART 10 - PROOF OF SERVICE
I hereby certify that a copy of the foregoing Form EOIR-42B was sent to to the Counsel for the DHS (U.S. Immigration and Customs EnforcementICE) on
at:
(Month, Day, Year)

(Email Address or Physical Address (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)

Please continue answers on a separate sheet as needed.
(8)

Form EOIR-42B
Rev. Apr. 2026
Exp. TBD