Application for Asylum and for Withholding of Removal (United States)
This form is an application for asylum and withholding removal or deportation from the United States. The form provided here is simply a sample of what the actual Form I-589 looks like.
U.S. Department of Homeland Security
Bureau of Citizenship and Immigration Services
U.S. Department of Justice
Executive Office for Immigration Review
Application for Asylum and for Withholding of Removal
Start Here - Please Type or Print. USE BLACK INK. SEE THE SEPARATE INSTRUCTION PAMPHLET FOR INFORMATION ABOUT ELIGIBILITY AND HOW TO COMPLETE AND FILE THIS APPLICATION. (Note: There is NO filing fee for this application.)
Please check the box if you also want to apply for withholding of removal under the Convention Against Torture. ____
PART A. I. INFORMATION ABOUT YOU
1. Alien Registration Number(s) (A#'s) (If any) __________________________
2. Social Security No. (If any) __________________________
3. Complete Last Name __________________________
4. First Name __________________________
5. Middle Name __________________________
6. What other names have you used? (Include maiden name and aliases.) __________________________
7. Residence in the U.S. C/O __________________________
Telephone Number __________________________
Street Number and Name __________________________
Apt. No. __________________________
City __________________________
State __________________________
ZIP Code __________________________
8. Mailing Address in the U.S., if other than above __________________________
Telephone Number __________________________
Street Number and Name __________________________
Apt. No. __________________________
City __________________________
State __________________________
ZIP Code __________________________
9. Sex ____ Male ____ Female
10. Marital Status: ____ Single ____ Married ____ Divorced ____ Widowed
11. Date of Birth (Mo/Day/Yr) __________________________
12. City and Country of Birth __________________________
13. Present Nationality (Citizenship) __________________________
14. Nationality at Birth __________________________
15. Race, Ethnic or Tribal Group __________________________
16. Religion __________________________
17. Check the box, a through c that applies:
a. ____ I have never been in immigration court proceedings.
b. ____ I am now in immigration court proceedings.
c. ____ I am not now in immigration court proceedings, but I have been in the past.
18. Complete 18 a through c.
a. When did you last leave your country? (Mo/Day/Yr) __________________________
b. What is your current I-94 Number, if any? __________________________
c. Please list each entry to the U.S. beginning with your most recent entry.
List date (Mo/Day/Yr), place, and your status for each entry. (Attach additional sheets as needed.)
Date __________________________
Place __________________________
Status __________________________
Date Status Expires __________________________
Date __________________________
Place __________________________
Status __________________________
Date __________________________
Place __________________________
Status __________________________
19. What country issued your last passport or travel document? __________________________
20. Passport # __________________________
Travel Document # __________________________
21. Expiration Date (Mo/Day/Yr) __________________________
22. What is your native language? __________________________
23. Are you fluent in English? ____ Yes ____ No
24. What other languages do you speak fluently? __________________________
FOR EOIR USE ONLY
FOR BCIS USE
Interview Date: __________________________
Decision:
____ Approval Date: __________________________
____ Denial Date: __________________________
____ Referral Date: __________________________
Asylum Officer ID# __________________________
PART A. II. INFORMATION ABOUT YOUR SPOUSE AND CHILDREN
Your Spouse. ____ I am not married. (Skip to Your Children, below.)
1. Alien Registration Number (A#) (If any) __________________________
2. Passport/ID Card No. (If any) __________________________
3. Date of Birth (Mo/Day/Yr) __________________________
4. Social Security No. (If any) __________________________
5. Complete Last Name __________________________
6. First Name __________________________
7. Middle Name __________________________
8. Maiden Name __________________________
9. Date of Marriage (Mo/Day/Yr) __________________________
10. Place of Marriage __________________________
11. City and Country of Birth __________________________
12. Nationality (Citizenship) __________________________
13. Race, Ethnic or Tribal Group __________________________
14. Sex ____ Male ____ Female
15. Is this person in the U.S.? ____ Yes (Complete blocks 16 to 24.) ____ No (Specify location)
16. Place of last entry in the U.S. __________________________
17. Date of last entry in the U.S. (Mo/Day/Yr) __________________________
18. I-94 No. (If any) __________________________
19. Status when last admitted (Visa type, if any) __________________________
20. What is your spouse's current status? __________________________
21. What is the expiration date of his/her authorized stay, if any? (Mo/Day/Yr) __________________________
22. Is your spouse in immigration court proceedings? ____ Yes ____ No
23. If previously in the U.S., date of previous arrival (Mo/Day/Yr) __________________________
24. If in the U.S., is your spouse to be included in this application? (Check the appropriate box.)
____ Yes (Attach one (1) photograph of your spouse in the upper right hand corner of page 9 on the extra copy of the application submitted for this person.)
____ No
Your Children. Please list ALL of your children, regardless of age, location, or marital status.
____ I do not have any children. (Skip to Part A. III., Information about Your Background.)
____ I do have children. Total number of children
(Use Supplement A Form I-589 or attach additional pages and documentation if you have more than four (4) children.)
1. Alien Registration Number (A#) __________________________
2. Passport/ID Card No. (If any) __________________________
3. Marital Status (Married, Single, Divorced, Widowed) __________________________
4. Social Security No. (If any) __________________________
5. Complete Last Name __________________________
6. First Name __________________________
7. Middle Name __________________________
8. Date of Birth (Mo/Day/Yr) __________________________
9. City and Country of Birth __________________________
10. Nationality (Citizenship) __________________________
11. Race, Ethnic or Tribal Group __________________________
12. Sex ____ Male ____ Female
13. Is this child in the U.S.? ____ Yes (Complete blocks 14 to 21.) ____ No (Specify Location)
14. Place of last entry in the U.S. __________________________
15. Date of last entry in the U.S.? (Mo/Day/Yr)? __________________________
16. I-94 No. (If any) __________________________
17. Status when last admitted (Visa type, if any) __________________________
18. What is your child's current status? __________________________
19. What is the expiration date of his/her authorized stay, if any? (Mo/Day/Yr) __________________________
20. Is your child in immigration court proceedings? ____ Yes ____ No
21. If in the U.S., is this child to be included in this application? (Check the appropriate box.)
____ Yes (Attach one (1) photograph of your child in the upper right hand corner of page 9 on the extra copy of the application submitted for this person.)
No ____
PART A. III. INFORMATION ABOUT YOUR BACKGROUND
1. Please list your last address where you lived before coming to the U.S. If this is not the country where you fear persecution, also list the last address in the country where you fear persecution. (List Address, City/Town, Department, Province, or State, and Country.) (Use Supplement B Form I-589 or additional sheets of paper if necessary.)
Number and Street (Provide if available) __________________________
City/Town __________________________
Department, Province or State __________________________
Country __________________________
Dates __________________________
From (Mo/Yr) __________________________
To (Mo/Yr) __________________________
2. Provide the following information about your residences during the last five years. List your present address first. (Use Supplement Form B or additional sheets of paper if necessary.)
Number and Street (Provide if available) __________________________
City/Town __________________________
Department, Province or State __________________________
Country __________________________
Dates __________________________
From (Mo/Yr) __________________________
To (Mo/Yr) __________________________
3. Provide the following information about your education, beginning with the most recent. (Use Supplement B Form I-589 or additional sheets of paper if necessary.)
Name of School __________________________
Type of School __________________________
Location (Address) __________________________
Attended From (Mo/Yr) __________________________ To (Mo/Yr) __________________________
4. Provide the following information about your employment during the last five years. List your present employment first. (Use Supplement Form B or additional sheets of paper if necessary.)
Name and Address of Employer __________________________
Your Occupation __________________________
Dates From (Mo/Yr) __________________________ To (Mo/Yr) __________________________
5. Provide the following information about your parents and siblings (brother and sisters). Check box if the person is deceased. (Use Supplement B Form I-589 or additional sheets of paper if necessary.)
Mother Name __________________________
City/Town and Country of Birth __________________________
Current Location __________________________
Father __________________________
City/Town and Country of Birth __________________________
Current Location __________________________
Siblings __________________________
City/Town and Country of Birth __________________________
Current Location __________________________
Siblings __________________________
City/Town and Country of Birth __________________________
Current Location __________________________
PART B. INFORMATION ABOUT YOUR APPLICATION
(Use Supplement B Form I-589 or attach additional sheets of paper as needed to complete your responses to the questions contained in PART B.)
When answering the following questions about your asylum or other protection claim (withholding of removal under 241(b)(3) of the Act or withholding of removal under the Convention Against Torture) you should provide a detailed and specific account of the basis of your claim to asylum or other protection. To the best of your ability, provide specific dates, places, and descriptions about each event or action described. You should attach documents evidencing the general conditions in the country from which you are seeking asylum or other protection and the specific facts on which you are relying to support your claim. If this documentation is unavailable or you are not providing this documentation with your application, please explain why in your responses to the following questions. Refer to Instructions, Part 1: Filing Instructions, Section II, ''Basis of Eligibility,'' Parts A - D, Section V, ''Completing the Form,'' Part B, and Section VII, "Additional Documents that You Should Submit" for more information on completing this section of the form.
1. Why are you applying for asylum or withholding of removal under section 241(b)(3) of the Act, or for withholding of removal under the Convention Against Torture? Check the appropriate box (es) below and then provide detailed answers to questions A and B below:
I am seeking asylum or withholding of removal based on
____ Race
____ Religion
____ Nationality
____ Political opinion
____ Membership in a particular social group
____ Torture Convention
A. Have you, your family, or close friends or colleagues ever experienced harm or mistreatment or threats in the past by anyone?
____ No ____ Yes If your answer is ''Yes,'' explain in detail:
1) What happened;
2) When the harm or mistreatment or threats occurred;
3) Who caused the harm or mistreatment or threats; and
4) Why you believe the harm or mistreatment or threats occurred.
B. Do you fear harm or mistreatment if you return to your home country?
____ No ____ Yes If your answer is ''Yes,'' explain in detail:
1) What harm or mistreatment you fear;
2) Who you believe would harm or mistreat you; and
3) Why you believe you would or could be harmed or mistreated.
2. Have you or your family members ever been accused, charged, arrested, detained, interrogated, convicted and sentenced, or imprisoned in any country other than the United States?
____ No ____ Yes If ''Yes,'' explain the circumstances and reasons for the action.
3. A. Have you or your family members ever belonged to or been associated with any organizations or groups in your home country, such as, but not limited to, a political party, student group, labor union, religious organization, military or paramilitary group, civil patrol, guerrilla organization, ethnic group, human rights group, or the press or media?
____ No ____ Yes If ''Yes,'' describe for each person the level of participation, any leadership or other positions held, and the length of time you or your family members were involved in each organization or activity.
B. Do you or your family members continue to participate in any way in these organizations or groups?
____ No ____ Yes If ''Yes,'' describe for each person, your or your family members' current level of participation, any leadership or other positions currently held, and the length of time you or your family members have been involved in each organization or group.
4. Are you afraid of being subjected to torture in your home country or any other country to which you may be returned?
____ No ____ Yes If ''Yes,'' explain why you are afraid and describe the nature of the torture you fear, by whom, and why it would be inflicted.
PART C. ADDITIONAL INFORMATION ABOUT YOUR APPLICATION
(Use Supplement B Form I-589 or attach additional sheets of paper as needed to complete your responses to the questions contained in Part C.)
1. Have you, your spouse, your child(ren), your parents, or your siblings ever applied to the United States Government for refugee status, asylum, or withholding of removal? ____ No ____ Yes
If "Yes" explain the decision and what happened to any status you, your spouse, your child(ren), your parents, or your siblings received as a result of that decision. Please indicate whether or not you were included in a parent or spouse's application. If so, please include your parent or spouse's A- number in your response. If you have been denied asylum by an Immigration Judge or the Board of Immigration Appeals, please describe any change(s) in conditions in your country or your own personal circumstances since the date of the denial that may affect your eligibility for asylum.
2. A. After leaving the country from which you are claiming asylum, did you or your spouse or child(ren), who are now in the United States, travel through or reside in any other country before entering the United States? ____ No ____ Yes
B. Have you, your spouse, your child(ren), or other family members such as your parents or siblings ever applied for or received any lawful status in any country other than the one from which you are now claiming asylum? ____ No ____ Yes
If ''Yes'' to either or both questions (2A and/or 2B), provide for each person the following: the name of each country and the length of stay; the person's status while there; the reasons for leaving; whether the person is entitled to return for lawful residence purposes; and whether the person applied for refugee status or for asylum while there, and, if not, why he or she did not do so.
3. Have you, your spouse, or child(ren) ever ordered, incited, assisted, or otherwise participated in causing harm or suffering to any person because of his or her race, religion, nationality, membership in a particular social group or belief in a particular political opinion?
____ No ____ Yes If ''Yes,'' describe in detail each such incident and your own or your spouse's or child(ren)'s involvement.
4. After you left the country where you were harmed or fear harm, did you return to that country?
____ No ____ Yes If ''Yes,'' describe in detail the circumstances of your visit (for example, the date(s) of the trip(s), the purpose(s) of the trip(s), and the length of time you remained in that country for the visit(s)).
5. Are you filing the application more than one year after your last arrival in the United States?
____ No ____ Yes If ''Yes,'' explain why you did not file within the first year after you arrived. You should be prepared to explain at your interview or hearing why you did not file your asylum application within the first year after you arrived. For guidance in answering this question, see Instructions, Part 1: Filing Instructions, Section V. ''Completing the Form,'' Part C.
6. Have you or any member of your family included in the application ever committed any crime and/or been arrested, charged, convicted and sentenced for any crimes in the United States?
____ No ____ Yes If ''Yes,'' for each instance, specify in your response what occurred and the circumstances; dates; length of sentence received; location; the duration of the detention or imprisonment; the reason(s) for the detention or conviction; any formal charges that were lodged against you or your relatives included in your application; the reason(s) for release. Attach documents referring to these incidents, if they are available, or an explanation of why documents are not available.
PART D. YOUR SIGNATURE
After reading the information regarding penalties in the instructions, complete and sign below. If someone helped you prepare this application, he or she must complete Part E.
I certify, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it are all true and correct. Title 18, United States Code, Section 1546, provides in part: ''Whoever knowingly makes under oath, or as permitted under penalty of perjury under Section 1746 of Title 28, United States Code, knowingly subscribes as true, any false statement with respect to a material fact in any application, affidavit, or knowingly presents any such application, affidavit, or other document required by the immigration laws or regulations prescribed thereunder, or knowingly presents any such application, affidavit, or other document containing any such false statement or which fails to contain any reasonable basis in law or fact - shall be fined in accordance with this title or imprisoned not more than five years, or both.'' I authorize the release of any information from my record which the Bureau of Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking.
Staple your photograph here or the photograph of the family member to be included on the extra copy of the application submitted for that person.
WARNING: Applicants who are in the United States illegally are subject to removal if their asylum or withholding claims are not granted by an Asylum Officer or an Immigration Judge. Any information provided in completing this application may be used as a basis for the institution of, or as evidence in, removal proceedings even if the application is later withdrawn. Applicants determined to have knowingly made a frivolous application for asylum will be permanently ineligible for any benefits under the Immigration and Nationality Act. See 208(d)(6) of the Act and 8 CFR 208.20.
Print Complete Name
Write your name in your native alphabet
Did your spouse, parent, or child(ren) assist you in completing this application? ____ No ____ Yes (If ''Yes,'' list the name and relationship.)
__________________________ (Name)
__________________________ (Relationship)
__________________________ (Name)
__________________________ (Relationship)
Did someone other than your spouse, parent, or child(ren) prepare this application? ____ No ____ Yes (If ''Yes,'' complete Part E)
Asylum applicants may be represented by counsel. Have you been provided with a list of persons who may be available to assist you, at little or no cost, with your asylum claim? ____ No ____ Yes
Signature of Applicant (The person in Part A. I.)
[__________________________] Sign your name so it all appears within the brackets
__________________________ Date (Mo/Day/Yr)
PART E. DECLARATION OF PERSON PREPARING FORM IF OTHER THAN APPLICANT, SPOUSE, PARENT OR CHILD
I declare that I have prepared this application at the request of the person named in Part D, that the responses provided are based on all information of which I have knowledge, or which was provided to me by the applicant and that the completed application was read to the applicant in his or her native language or a language he or she understands for verification before he or she signed the application in my presence. I am aware that the knowing placement of false information on the Form I-589 may also subject me to civil penalties under 8 U.S.C. 1324(c).
Signature of Preparer __________________________
Print Complete Name __________________________
Daytime Telephone Number __________________________
Address of Preparer: Street Number and Name __________________________
Apt. No. __________________________
City __________________________
State __________________________
ZIP Code __________________________
PART F. TO BE COMPLETED AT INTERVIEW OR HEARING
You will be asked to complete this Part when you appear before an Asylum Officer of theU.S. Department of Homeland Security, Bureau of Citizenship and Immigration Services (BCIS), or an Immigration Judge of the U.S. Department of Justice, Executive Office for Immigration Review (EOIR) for examination.
I swear (affirm) that I know the contents of this application that I am signing, including the attached documents and supplements, that they are all true to the best of my knowledge taking into account correction(s) numbered __________________________ to __________________________ that were made by me or at my request.
Signature of Applicant __________________________
Write Your Name in Your Native Alphabet __________________________
Signed and sworn to before me by the above named applicant on:
Date (Mo/Day/Yr) __________________________
Signature of Asylum Officer or Immigration Judge __________________________
A # (If available) __________________________
Date __________________________
Applicant's Name __________________________
Applicant's Signature __________________________
LIST ALL OF YOUR CHILDREN, REGARDLESS OF AGE OR MARITAL STATUS.
(Use this form and attach additional pages and documentation as needed to your application if you have more than four (4) children.)
1. Alien Registration Number (A#)(If any) __________________________
2. Passport/ID Card No. (If any) __________________________
3. Marital Status (Married, Single, Divorced, Widowed) __________________________
4. Social Security No. (If any) __________________________
5. Complete Last Name __________________________
6. First Name __________________________
7. Middle Name __________________________
8. Date of Birth (Mo/Day/Yr) __________________________
9. City and Country of Birth __________________________
10. Nationality (Citizenship) __________________________
11. Race, Ethnic or Tribal Group __________________________
12. Sex Male Female __________________________
13. Is this child in the U.S.? ____ Yes (Complete blocks 14 to 21.) ____ No (Specify Location) __________________________
14. Place of last entry in the U.S.? __________________________
15. Date of last entry in the U.S.? __________________________
16. I-94 No. (If any) __________________________
17. Status when last admitted (Visa type, if any) __________________________
18. What is your child's current status? __________________________
19. What is the expiration date of his/her authorized stay, if any? (Mo/Day/Yr) __________________________
20. Is your child in immigration court proceedings? ____ Yes ____ No
21. If in the U.S., is this child to be included in this application? (Check the appropriate box.)
____ Yes (Attach one (1) photograph of your child in the upper right hand corner of page 9 on the extra copy of the application submitted for this person.)
____ No