Application for Asylum and Withholding of Removal

Application for Suspension of Deportation (Form EOIR-40)

U.S. Department of Justice
Executive Office for Immigration Review
OMB #1125-0025

Please use a separate sheet for additional entries. Please type or print.

PART 1 - INFORMATION ABOUT YOURSELF

1) My legal name is:

2) Alien Registration Number:

3) My name given at birth was:

4) Birth Place:

5) Date of Birth:

6) Gender: Male Female

7) Height: 8) Hair Color: 9) Eye Color:

10) Current Nationality & Citizenship:

11) Social Security Number:

12) Home Phone Number: 13) Work Phone Number:

14) I currently reside at:

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

16) During the last 10 years, I resided in the following locations in the United States:

Street and Number - Apt. or Room# - City or Town - State - ZIP Code | Resided From | Resided To

17) Please state the basis for your claim that your deportation would result in extreme hardship:

Family member hardship categories:

PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES

18) I first entered the United States under the name of:

19) I first entered the United States on:

20) Place or port of first entry:

21) I entered: as a Visitor as a Student without inspection Other

Explain other:

22) Period for which admitted: to

23) My last extension of stay in the United States expired on:

24) If not inspected or if entry occurred at other than a regular port, describe the circumstances:

25) Since the date of my first entry I departed from and returned to the United States:

If you have never departed from the United States since your original date of entry, mark an X in the box:

26) Have you ever departed the United States: Yes No

a) under an order of deportation? Yes No

b) pursuant to a grant of voluntary departure? Yes No

PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE

27) I am not married: I am married:

28) If married, the name of my spouse is:

29) Date of marriage:

30) The marriage took place in:

31) Birth place of spouse:

32) My spouse currently resides at:

33) Birth date of spouse:

34) My spouse is a citizen of:

35) If your spouse is other than a native born United States citizen, answer the following:

36) My spouse is employed: is is not

37) I have been previously married:

38) My present spouse has been previously married:

39) Have you been ordered by any court, or are otherwise under any legal obligation, to provide child support and/or spousal maintenance? Yes No

PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS

40) Since my entry into the United States, I have been employed by the following named persons or firms:

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

42) My assets (and if married, my spouse's assets) are:

43) I have received public or private relief or assistance: have have not

44) Years in which you have filed an income tax return:

PART 6 - INFORMATION ABOUT YOUR FAMILY

45) I have children.

46) 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, and/or Country of Last Residence Yes No.

47) Members of my family have received public or private relief or assistance: have have not

48) Please give the requested information about your parents, brothers, sisters, aunts, uncles, and grandparents:

49) If based on hardship to a parent or parents, give the date and place of arrival in the United States and details of admission:

50) My father employed: is is not

51) My mother employed: is is not

52) My parent's assets are:

PART 7 - MISCELLANEOUS INFORMATION

53) I have acquired the status of an exchange alien after entry into the United States: have have not

54) I have submitted address reports as required by section 265: have have not

55) I have ever been arrested, summoned into court, convicted, fined, imprisoned, placed on probation, or forfeited collateral: have have never

56) Have you ever served in the Armed Forces of the United States? Yes No

57) Have you ever left the United States or the jurisdiction of the district where you registered for the draft to avoid being drafted? Yes No

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

59) If male, did you register under the Selective Service (Draft) Law? Yes No

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

61) Membership in political organizations and similar groups since your 16th birthday:

62) Have you ever been ordered deported, overstayed voluntary departure, or failed to appear for deportation?

63) Have you ever been a habitual drinker, illegal gambler, false witness, prostitute, polygamist, aided illegal entry, or controlled substance trafficker?

64) I can arrange a trip outside the United States to obtain an immigrant visa: can can not

65) Certificates or other supporting documents attached: