Beruflich Dokumente
Kultur Dokumente
Part 1. Information About the Alien 10. State the reasons for abandoning lawful permanent
resident status.
1. Alien Registration Number (A-Number)
► A-
5. Country of Birth
12.a. I am submitting Form I-407 outside of the United
States in-person.
6. Country of Citizenship or Nationality 12.b. I am submitting Form I-407 outside of the United
States by mail.
12.c. I am submitting Form I-407 at a U.S. Port of Entry.
7. Date of Last Departure from the United States
(mm/dd/yyyy)
Certification
Mailing Address Abroad I knowingly, willingly, and affirmatively declare that I have no
intention of residing permanently in the United States, and that
8.a. In Care Of Name (if applicable) by signing and submitting this form, I intend to record the fact
that I have knowingly and willingly abandoned my lawful
permanent resident status in the United States. I have been
8.b. Street Number informed of, and I understand my rights to a hearing before an
and Name immigration judge about whether I have abandoned my lawful
8.c. Apt. Ste. Flr. permanent resident status in the United States. By signing and
submitting this form, I knowingly, willingly, and affirmatively
8.d. City or Town waive my rights to such a hearing.
13.a. Signature of Alien (sign in ink)
8.e. Province or State
Appointment as guardian
3. A copy of the signed Form I-407 was provided to the alien.
Yes No
Part 2. Certification and Signature of the
Interpreter DHS/Consular Officer Information
4.a. Name of DHS/Consular Officer
Interpreter Certification
I certify that:
4.b. Signature of DHS/Consular Officer (sign in ink)
I am fluent in English and
(write the other language in the box provided above).
4.c. Title of DHS/Consular Officer
I further certify that I have read each and every question and
instruction on this form, as well as the answer to each and every
question on this form, in the language provided above; and
4.d. Name of DHS Component, if signed by a DHS officer