Fill and Sign the Application for Asylum and for Withholding of Removal I Form

U.S. Department of Justice Executive Office for Immigration ReviewOMB #1125-0025Application for Suspension of Deportation (Under Section 244 of the Immigration and Nationality Act) Fee Stamp Please use a separate sheet for additional entries. (1) PART 1 - INFORMATION ABOUT YOURSELF 1) My legal name is: (Last, First, Middle ) 5) Date of Birth: (Month, Day, Year ) 3) My name given at birth was: (Last, First, Middle ) 12) Home Phone Number: 13) Work Phone Number: ( ) 7) Height: 8) Hair Color: 9) Eye Color: 4) Birth Place: (Place, Country ) ( ) 15) I have been known by these additional name(s): 2) Alien Registration Number: 16) During the last 10 years, I resided in the following locations in the United States: (If less than 10 years, set forth the information for the period you have been in the United States.) List P RESENT ADDRESS FIRST, and work back in time. PART 2 - INFORMATION ABOUT THIS APPLICATION Street and Number - Apt. or Room# - City or Town - State - ZIP Code Resided From: Resided To: ( Month, Day, Year ) ( Month, Day, Year ) PRESENT I, the undersigned, hereby request that my deportation be suspended under the provisions of section 244 of the Immigration and Nationality Act (INA). I believe that I am eligible for suspension of deportation because such deportation would result in extreme hardship (or exceptional and extremely unusual hardship if I am subject to deportation under section 241 (a) (2), (3), or (4) of the INA) to: (Place a C in the box if the family member is a citizen of the United States, an L if the family member is a lawful permanent resident of the United States, an X if the family member is neither, and leave BLANK if not applicable.) Please state the basis for your claim that your deportation would result in extreme hardship to each of the individuals checked in the boxesabove: _____________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ With the exception of absences described in question #25, I have been physically present in the United States since: ( Month, Day, Year )______________________________________________ . 17) City or Town StateZIP Code Apt. number and/or in care of Number and Street r Male r Female 11) Social Security Number: 6) Gender: 14) I currently reside at: 10) Current Nationality & Citizenship: r Myself (and/or my) r Husband r Wife r Father r Mother r Child or Children. PLEASE READ ADVICE AND INSTRUCTIONS BEFORE FILLING IN FORM PLEASE TYPE OR PRINT Form EOIR-40 Expires 08/31/01 r I, or my child, have been battered or subjected to extreme cruelty by a United States citizen or lawful permanent resident spouse or parent. 27) I am not married: I am married: PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued on page 3) r r 29) Date of marriage: (Month, Day, Year ) 28) If married, the name of my spouse is: (Last, First, Middle ) 30) The marriage took place in: (Place and Country ) 35) If your spouse is other than a native born United States citizen, answer the following: He/she arrived in the United States at: (Place, City, and State ) _______________________________________________________ . He/she arrived in the United States on: (Month, Day, Year ) ________________________________________ . His/her alien registration number is: A# _____________________________________________________ . He/she was naturalized on (Month, Day, Year ) ____________________ at ____________________________________________ . 36) My spouse r - is r - 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) $ $ (Place, City, and State) 32) My spouse currently resides at: City or Town State/CountryZIP Code Apt. number and/or in care of Number and Street 34) My spouse is a citizen of: (Country ) 31) Birth place of spouse: (Place and Country ) 33) Birth date of spouse: (Month, Day, Year ) Please use a separate sheet for additional entries. (2) $ 24) If not inspected or if entry occurred at other than a regular port, describe the circumstances as accurately as possible: to 22) Period for which admitted: (Month, Day, Year ) 23) My last extension of stay in the United States expired on: (Month, Day, Year ) 25) 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 the box : r 1 2 Port of Return (Place or Port, City and State) Port of Departure (Place or Port, City and State) Port of Return (Place or Port, City and State) Return Date (Month, Day, Year) Departure Date (Month, Day, Year) Departure Date (Month, Day, Year) Return Date (Month, Day, Year) Purpose of Travel Manner of Return Manner of Return Purpose of Travel Destination Destination Inspected & Admitted? Port of Departure (Place or Port, City and State) 18) I first entered the United States under the name of: (Last, First, Middle )19) I first entered the United States on: (Month, Day, Year ) 20) Place or port of first entry: (Place or Port, City, and State ) 21) I entered: r as a Visitor, r as a Student, r without inspection, or r Other (Place an X in the correct box, if Other is selected please explain) : ___________________________________________________________________________________________________________. 26) Have you ever departed the United States: a) under an order of deportation? ----------------------------------- b) pursuant to a grant of voluntary departure? -------------------- Form EOIR-40 r Yes r No r Yes r No r Yes r No Inspected & Admitted? r Yes r No 39) 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? PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued ) PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS r - Yes r - No Name of prior spouse: (Last, First, Middle ) 37) I r - have r - 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.) Date marriage ended: Date marriage began: Name of prior spouse: (Last, First, Middle ) Date marriage ended: Date marriage began: Full Name and Address of Employer Earnings Per Week Type of Work (Approximate ) Performed 40) Since my entry 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.) ( Month, Day, Year ) ( Month, Day, Year )Employed To: Employed From: PRESENT $ $ $ 41) If self-employed, describe the nature of the business, the name of the business, its address, and net income derived therefrom: Cash, Stocks, and Bonds Real EstateAutomobile (dollar value - amount owed)Other (describe on line below)_______________________ TOTAL Self $ $$ $ $ Cash, Stocks, and Bonds Real EstateAutomobile (dollar value - amount owed)Other (describe on line below)_______________________ TOTAL $ $$ $ $ Jointly Owned with Spouse 42) My assets (and if married, my spouse's assets) in the United States and other countries, not including clothing and household necessities, are: Please use a separate sheet for additional entries. (3) Description or manner of how marriage was terminated or ended: ( Place and Country ) 38) My present spouse r - has r - has not been previously married: (If previously married, list the name of each prior spouse, the dates on which the marriage began and ended, the place where the marriage terminated, and describe how each marriage ended.) Place marriage ended: (Place and Country ) Description or manner of how marriage was terminated or ended: 43) I r - have r - have not received public or private relief or assistance (e.g. Welfare, Unemployment Benefits, Medicaid, ADC, 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 amount received during this time:___________________________________________ _________________ _______________________________________________________________________________________________________. 44) Please list each of the years in which you have filed an income tax return with the Internal Revenue Service: _______________ ___________________________________________________________________________________________________________. Place marriage ended: Form EOIR-40 (4)Please use a separate sheet for additional entries. Name: (Last, First, Middle ) Alien Registration Number: / /Relationship to Me: Birth Place: (Place and Country ) A#: Complete Address of Current Residence:_______________________________________________________ ________________________________________________________________________________________ / / A#: Complete Address of Current Residence:_______________________________________________________ ________________________________________________________________________________________ Citizen of What Country: Birth Date: (Month, Day , Year ) Immigration Status of Listed Relative PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued on page 5) 45) I have _______________ (Number of) children. Please list information for each child below, include assets and earnings information for children over the age of sixteen who have separate incomes: Name of Child: (Last, First, Middle ) Child's Alien Registration Number: Immigration Status of Child? Now Residing At: (Place and Country ) Birth Place: (Place and Country ) Citizen of What Country: Birth Date: (Month, Day, Year ) 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: $ ______________ 46) If your application is denied, would your spouse and all of your children accompany you to your: Country of Birth - r Yes r No, Country of Nationality - r Yes r No, and/or Country of Last Residence - r Yes r No. If you answered "NO" to any of the responses, please explain: _____________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ _______________________________________________________________________________________________________. 47) Members of my family, including my spouse and/or child(ren) r - have r - have not received public or private relief or assistance (e.g., Unemployment Benefits, Welfare, Medicaid, ADC, 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 amount received during this time: ______________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ______________________________________________________________________________________________________ . 48) Please give the requested information about your parents, brothers, sisters, aunts, uncles, and grandparents. As to residence, show street address, city, and state, if in the United States; otherwise show only country: Form EOIR-40 (5)Please use a separate sheet for additional entries. PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued) IF THIS APPLICATION IS BASED ON HARDSHIP TO A PARENT OR PARENTS, QUESTIONS 49 TO 52 MUST BE ANSWERED. 49) As to such parent who 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 manner and terms of admission into the United States: _____________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Cash, Stocks, and Bonds Real EstateAutomobile (dollar value - amount owed)Other (describe on line below)_______________________ TOTAL 52) My parent's assets in the United States and other countries not including clothing and household necessities are: 51) My mother r - is r - 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) $ 50) My father r - is r - 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) $ Cash, Stocks, and Bonds Real EstateAutomobile (dollar value - amount owed)Other (describe on line below)_______________________ TOTAL $ $$ $ $ $ $ $ $ $ Assets of father consist of the following: Assets of mother consist of the following: PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6) 53) I r - have r - have not acquired the status of an exchange alien after entry into the United States. 54) I r - have r - have not submitted address reports as required by section 265 of the Immigration and Nationality Act. 55) I r - have r - 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, any penalty imposed, any sentence imposed, and the time actually served)._____________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ 56) Have you ever served in the Armed Forces of the United States? r - Yes r - No . If "Yes", please state branch (Army, Navy, etc.) and service number. ________________________________________________________________________________ . Place of entry on duty: (Place, 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 ) __________________ . 57) 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? r Yes r No Form EOIR-40 59) If male, did you register under the Selective Service (Draft) Law of 1917, 1918, 1948, 1951, or later Draft Laws? 58) Have you ever deserted from the military or naval forces of the United States while the United States was at war? PART 7 - MISCELLANEOUS INFORMATION (Continued) r Yes r No If "Yes," please give date, Selective Service number, local draft board number, and your last draft classification:________________ _______________________________________________________________________________________________________ . Were you ever exempted from service because of conscientious objection, alienage, or any other reason ? r Yes r No (6) Please use a separate sheet for additional entries. 61) Member To: ( Month, Day, Year ) Name of Organization (Month, Day, Year ) Member From: Nature of Organization Location of Organization 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 16th birthday. Include any foreign military servicein this part. If none, write "NONE". Include the name of the organization, location, nature of the organization, and the dates ofmembership. r Yes r No 60) r Yes r No a habitual drinker? r Yes r No one whose income is derived principally from illegal gambling? r Yes r No one who has given false testimony for the purpose of obtaining immigration benefits? r Yes r No one who has engaged in prostitution or unlawful commercialized vice? r Yes r No involved in a serious criminal offense and have asserted immunity from prosecution? r Yes r No a polygamist? r Yes r No one who aided and/or abetted another to enter the United States illegally? r Yes r No a trafficker of a controlled substance, or a knowing assister, abettor, conspirator, or colluder with others in any such controlled substance (not including a single offense of simple possesion of 30 grams or less of marijuana)? r Yes r No been ordered deported? r Yes r No overstayed a grant of voluntary departure from an Immigration Judge or the Immigration and Naturalization Service (INS)? r Yes r No failed to appear for deportation? 62) Have you ever: 63) Have you ever been: 64) I r - can r - can not arrange a trip outside the United States to obtain an immigrant visa. If not, please explain: _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Form EOIR-40 PART 7 - MISCELLANEOUS INFORMATION (Continued) (7)Please use a separate sheet for additional entries. 65) The following certificates or other supporting documents are attached hereto as a part of this application: (Refer to the Instruction Sheet for documents which should be attached). Signature of Applicant (or attorney or representative) CERTIFICATE OF SERVICE I hereby certify that a copy of the foregoing was: r - delivered in person , r - mailed first class, postage prepaid on _______________________ ( Month, Day, Year) to _______________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________. Subscribed and sworn to before me by the above-named applicant at Immigration Judge Date: ( Month, Day, Year ) (Complete and true signature of applicant or parent or guardian) APPLICATION NOT TO BE SIGNED BELOW UNTIL APPLICANT APPEARS BEFORE AN IMMIGRATION JUDGE I do swear (affirm) that the contents of the above application, including the documents attached hereto, are true to the best of my knowledge, and that this application is now signed by me with my full, true name. Form EOIR-40