OMB No. 1615-0019; Expires 12/31/2012 Department of Homeland Security U.S. Citizenship and Immigration Services I-243, Application for Removal NOTE: Complete your application in duplicate. Take or mail it to a Department of Homeland Security office nearest your place of residence. A separate application must be filed by each applicant, except that children under 14 years of age may be included in a parent's application. Applicant's Request for Removal: Being in distress or in need of public aid from causes arising after entry, I hereby request to be removed from the United States at government expense. (First Name) 3. Present Address (Apt. No.) 4. (Middle Name) (Number and Street) 1. Name (Family Name) (City or Town) 7. Status at Entry (Please select one) Yes Other (Specify) _____________________ 9. Have you been issued a Reentry Permit? No Yes No (Country, district, province, or state) Removal is requested to: (City or town) 11. Do you have a Valid Passport or Travel Document for Yes entry into the country shown above? No 12. Have you previously filed an Application for Removal? Yes No 13. The persons listed below depend on me for support: (If none, write "None") Name Age Relationship 14. (Country of Citizenship/Nationality) Permanent Temporary Entered Without Inspection Visitor Resident Please attach any documents issued to you at time of entry 8. Do you have a Permanent Resident Card? 10. (Country) Name of vessel, airline, or other means of conveyance Port-of-Entry 6. Date of Entry into U.S (mm/dd/yyyy). File Number (Alien Registration Number) (Country, Province, or State) 5. Place of Birth (City or Town) Date of Birth (mm/dd/yyyy) 2. Will They Accompany You? Address Yes No List your nearest relatives in the country to which removal is requested: Age Name Address Relationship 15. Have you received assistance from a public or charitable institution association? (If so, complete the following and have an official of such organization complete the certificate on the reverse side. If not, skip to Question 16.) Yes No Complete Address Name of Institution or Association 16. If you have not received such assistance, indicate the financial circumstances that cause you to need public aid and attach any documentary evidence available to support your statements. 17. APPLICANT'S CERTIFICATION: I understand that if this application is granted, and I am removed from the United States, I will be ineligible to apply for or receive a visa or other documents for readmission, or to apply for admission to the United States, except with the prior approval of the Secretary of the Department of Homeland Security. I certify that the above statements are true and correct to the best of my knowledge and belief. (Signature of Applicant) 18. (Date) Signature of person preparing form, if other than applicant I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge. (Printed Name) (Address) ( (Signature of Preparer) ) (Telephone Number) (Date) E-mail address (If any) Form I-243 (Rev. 12/20/10) Y American LegalNet, Inc. www.FormsWorkFlow.com Certificate of Accredited Representative of Public or Charitable Institution From Which Alien Named Has Received Aid I, , being an accredited representative (Name of Accredited Representative) of (Give name of institution or association with which connected) hereby certify that the said , an applicant for removal under section 250 of the Immigration and Nationality Act, has received the following aid or assistance from the: (Signature) Date (Title) Our Authority to Collect This Information: The authority for collection of the information requested on this form is contained in 8 U.S.C. 1260. Submission of the information by an alien applicant for removal from the United States at U.S. Government expense is voluntary. The solicited information will be used principally by the Department of Homeland Security (DHS) to determine whether the applicant is eligible for removal from the United States under the provisions of section 250 of the Immigration and Nationality Act, 8 U.S.C. 1260. The information may also as a matter of routine use be disclosed to other Federal, state, local, and foreign law enforcement and regulatory agencies, the Department of Defense including any component thereof (if the applicant has served or is serving in the Armed Forces of the United States), the U.S. Department of State, Central Intelligence Agency, Interpol, and by individuals and organizations during the course of investigation to elicit further information required by the DHS to carry out its functions. Failure to provide any or all of the solicited information may result in the denial of the application for removal from the United States. An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 30 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Products Division, Office of the Executive Secretariat, 20 Massachusetts Avenue, N.W., Washington, DC 20529-2020. OMB No. 1615-0019. Do not mail your application to this address. Form I-243 (Rev. 12/20/10) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com