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Fillable Printable Form I-407

Fillable Printable Form I-407

Form I-407

Form I-407

Record of Abandonment of
Lawful Permanent Resident Status
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-407
OMB No. 1615-0130
Expires 03/31/2019
Alien Registration Number (A-Number)1.
Part 1. Information About the Alien
3.a.Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.Middle Name
7.Date of Last Departure from the United States
Form I-551 (Permanent Resident Card)
11.b.
List other documents surrendered (if any).11.c.
12.a.
12.c.I am submitting Form I-407 at a U.S. Port of Entry.
I am submitting Form I-407 outside of the United
States by mail.
12.b.
If the Form I-551 is not surrendered, select the reason why.
I am submitting Form I-407 outside of the United
States in-person.
11.a.
Documents Surrendered and Location of
Submission
NoYes
A-
USCIS Online Account Number (if any)2.
State the reasons for abandoning lawful permanent
resident status.
(mm/dd/yyyy)
10.
LostOtherStolenMutilated
4.Date of Birth
5.Country of Birth
(mm/dd/yyyy)
6.
Country of Citizenship or Nationality
Your Full Legal Name
Other Information
Country
8.g.
8.f. Postal Code
8.e.Province or State
8.d.
City or Town
8.a.
In Care Of Name (if applicable)
Street Number
and Name
8.b.
8.c.
Ste.Flr.Apt.
Mailing Address Abroad
E-mail Address (if any)9.
I knowingly, willingly, and affirmatively declare that I have no
intention of residing permanently in the United States, and that
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
informed of, and I understand my rights to a hearing before an
immigration judge about whether I have abandoned my lawful
permanent resident status in the United States. By signing and
submitting this form, I knowingly, willingly, and affirmatively
waive my rights to such a hearing.
13.a.Signature of Alien (sign in ink)
13.b.Date of Signature (mm/dd/yyyy)
Certification
NOTE: Signing this form is voluntary. U.S. law does not
require you to complete, sign, or submit this form. You may
request a hearing before an immigration judge if you disagree
with a DHS allegation that you have abandoned your lawful
permanent residence.
Form I-407 03/31/17 YPage 1 of 2
14.b.
Date of Signature (mm/dd/yyyy)14.c.
Name of Parents, Custodial Parents, or Legal Guardian
As the parents or guardian of the alien minor who is identified
in Part 1. of this form, I/we consent to the alien minor's
submission of this form.
14.a.
Signature of Parents, Custodial Parents, or Legal Guardian
(sign in ink)
For Consent of Parents, Custodial Parents, or Legal
Guardian to Submit Form I-407 for Minors 17 Years
of Age or Younger
If signed by only one parent, custodian, or legal guardian,
indicate evidence to show sole parental, custodial, or legal
guardianship responsibility.
Award of sole legal custody
Termination of other parent's rights
14.d.
Death of other parent
The alien has informed me that he or she understands each and
every instruction and question on the form, as well as the
answer to each and every question.
1.c.
1.a.Signature of Interpreter (if applicable) (sign in ink)
Date of Signature (mm/dd/yyyy)
Instructions to officer: Select Item Number1. if you
interviewed the alien. If you did not, select Item Number 2.
and state the basis for your conclusion that the alien may have
abandoned lawful permanent resident status. Sign the form and
provide other information requested.
Part 3. For Government Use Only
I certify that I personally interviewed the alien who is
identified in Part 1., who has signed this Form I-407,
and that I advised the alien of the hearing rights
specified in the Instructions. The alien stated he or
she fully understands the effect of signing this Form
I-407. I further certify that, if an interpreter was
used, I confirmed that the alien understood the
interpreter.
1.
I certify that I was not able to interview the alien who
is identified in Part 1. of this Form I-407. My basis
for concluding that the alien may have abandoned
lawful permanent resident status is:
2.
1.b. Full Name of Interpreter
A copy of the signed Form I-407 was provided to the alien.3.
No
Yes
Check all that apply:
Part 1. Information About the Alien (continued)
Interpreter Certification
I certify that:
I am fluent in English and
(write the other language in the box provided above).
Part 2. Certification and Signature of the
Interpreter
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.e. Date of Signature (mm/dd/yyyy)
DHS/Consular Officer Information
4.a.
Title of DHS/Consular Officer
4.d.Name of DHS Component, if signed by a DHS officer
4.c.
Name of DHS/Consular Officer
4.b.Signature of DHS/Consular Officer (sign in ink)
Appointment as guardian
Form I-407 03/31/17 YPage 2 of 2
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