Professional Documents
Culture Documents
Part 1. Information About The Alien: Documents Surrendered and Location of Submission Your Full Legal Name
Part 1. Information About The Alien: Documents Surrendered and Location of Submission Your Full Legal Name
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
Dominican Republic States in-person.
6. Country of Citizenship or Nationality 12.b. I am submitting Form I-407 outside of the United
Dominican Republic 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) 10/12/2014
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