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Record of Abandonment of

Lawful Permanent Resident Status USCIS


Form I-407
Department of Homeland Security OMB No. 1615-0130
U.S. Citizenship and Immigration Services Expires 03/31/2019

Part 1. Information About the Alien 10. State the reasons for abandoning lawful permanent
resident status.
1. Alien Registration Number (A-Number)
► A-

2. USCIS Online Account Number (if any)


Your Full Legal Name Documents Surrendered and Location of


3.a. Family Name Submission
(Last Name)
3.b. Given Name 11.a. Form I-551 (Permanent Resident Card) Yes No
(First Name)
11.b. If the Form I-551 is not surrendered, select the reason why.
3.c. Middle Name
Lost Stolen Mutilated Other

Other Information 11.c. List other documents surrendered (if any).

4. Date of Birth (mm/dd/yyyy)

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

13.b. Date of Signature (mm/dd/yyyy)


8.f. Postal Code
NOTE: Signing this form is voluntary. U.S. law does not
8.g. Country
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
9. E-mail Address (if any)
permanent residence.

Form I-407 03/31/17 Y Page 1 of 2


The alien has informed me that he or she understands each and
Part 1. Information About the Alien (continued)
every instruction and question on the form, as well as the
answer to each and every question.
For Consent of Parents, Custodial Parents, or Legal
Guardian to Submit Form I-407 for Minors 17 Years 1.a. Signature of Interpreter (if applicable) (sign in ink)
of Age or Younger
As the parents or guardian of the alien minor who is identified 1.b. Full Name of Interpreter
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 1.c. Date of Signature (mm/dd/yyyy)
(sign in ink)

Part 3. For Government Use Only


Instructions to officer: Select Item Number 1. if you
interviewed the alien. If you did not, select Item Number 2.
14.b. Name of Parents, Custodial Parents, or Legal Guardian
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.
1. I certify that I personally interviewed the alien who is
14.c. Date of Signature (mm/dd/yyyy) 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
If signed by only one parent, custodian, or legal guardian,
she fully understands the effect of signing this Form
indicate evidence to show sole parental, custodial, or legal
I-407. I further certify that, if an interpreter was
guardianship responsibility.
used, I confirmed that the alien understood the
14.d. Check all that apply: interpreter.
Death of other parent 2. 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
Termination of other parent's rights lawful permanent resident status is:

Award of sole legal custody

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

4.e. Date of Signature (mm/dd/yyyy)

Form I-407 03/31/17 Y Page 2 of 2