U.S. Department of Justice
Executive Office for Immigration Review
OMB #1125-0025
Application 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 PRESENT 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 boxes
above: _________________________________________________________________