U.S. Department of Justice
Executive Office for Immigration Review
3) My name given at birth was: (Last, First, Middle)
5 ) Date of Birth: (~onth, Our, Year)
10) Current Nationality & Citizenship:
14) I currently reside at:
6) Gender:
1 1) Social Security Number:
0 Male 0 Female
Ap:. number and/or in cam of
Number and Sneer
CIN or Town
Sfarc
L/P cmfc
.,
OMB#l125-0001;Expires08/3
1/05
Application for Cancellation of Removal
for Certain Permanent Residents
4) Birth Place: (City, Country)
7) Height:
8) Hair Color:
9) Eye Color:
12) Home Phone Number:
15) I have been known by these additional name(s):
13) Work Phone Number:
0 0
PLEASE READ ADVICE AND INSTRUCTIONS
BEFORE FILLING IN FORM
PLEASE TYPE OR PRINT
Resided From:
(Month. Duy. Year)
StreetandNumber - Apt. orRoom# - CityorTown - State - ZIPCode
2) Alien Registration Number:
I
1) My present true name is: (Last, First, Middle)
I
Resided To:
(Month. Day, Year)
16) I have resided in the following locations in the United States: (List PRESENT ADDRESS FIRST, and work back in time for at least 7
years.)
I
I
I PRESENT I
7) I, the undersigned, hereby request that my removal be canceled under the provisions of section 240A(a) of the Immigration and
Nationality Act (INA). I believe that 1 am eligible for this relief because 1 have been a lawful permanent resident alien for 5 or more
years, have 7 years of continuous residence in the United States, and have not been convicted of an aggravated felony. I was
admitted as or adjusted to the status of an alien lawfully admitted for permanent residence on
(date)
Please use a separate sheet for additional entries.
FOITI EOIR-42A
(1)
August 2002