OMB No. 1615-0019; Expires 11/30/2010

Department of Homeland Security
U.S. Citizenship and Immigration ServicesI-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. Aseparate 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.
1. Name (Family Name)
3. Present Address (Apt. No.)
4.

(First Name)(Middle Name)(Number and Street)(City or Town)

5. Place of Birth (City or Town)

Date of Birth (mm/dd/yyyy)

2.

File Number (Alien Registration Number)(Country)(Country, Province, or State)(Country of Citizenship/Nationality)

Name of vessel, airline, or other means of conveyance

6. Date of Entry into U.S (mm/dd/yyyy).

Port-of-Entry

7. Status at Entry (Please select one)

Permanent
Temporary
Entered Without Inspection
VisitorResident
Please attach any documents issued to you at time of entry

8. Do you have a Permanent Resident Card?
10.

Yes

_____________________

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 forentry into the country shown above?

Yes

No

12. Have you previously filed an Application for Removal?
YesNo

13. The persons listed below depend on me for support: (If none, write "None")
Name
AgeRelationship

14.

Other (Specify)

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
Name of Institution or Association

Complete Address

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 theDepartment 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. 09/14/09) N

Certificate of Accredited Representative of Public or Charitable Institution
From Which Alien Named Has Received AidI,of(Name of Accredited Representative), being an accredited representative(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 isvoluntary. The solicited information will be used principally by the Department of Homeland Security (DHS) to determine whether theapplicant 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 isserving in the Armed Forces of the United States), the U.S. Department of State, Central Intelligence Agency, Interpol, and byindividuals 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 theUnited 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, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008,Washington, DC 20529-2210. OMB No. 1615-0019. Do not mail your application to this address.

Form I-243 (Rev. 09/14/09) N Page 2