Case 3:18-cv-00428-DMS-MDD Document 148-2 Filed 07/24/18 PageID.2467 Page 2 of 2

IMPORTANT
Instructions: This information on this page must be read to the alien parent in a language that he/she
understands. The Notice must be given to the alien parent at the same time as this form. The alien parent
should indicate which option he/she is choosing by signing the appropriate box below.

You DO NOT have to agree to removal from the United States in order to be reunified with your
child. Even if you continue to fight your case, the government must still reunify you.
IF YOU LOSE YOUR CASE AND THE GOVERNMENT IS GOING TO REMOVE YOU
FROM THE UNITED STATES, you must decide at that time whether you want your child to
leave the United States with you.
Parent Name / Nombre de Padre:________________________________________________________
Parent A # / A # de Padre: ______________________________________________________________
Country of Citizenship / Pais de Ciudadania: ______________________________________________
Detention Facility / El Centro de Detención: _______________________________________________
Child(ren) Name(s) / Nombre de Hijo: ___________________________________________________
Child(ren) A # / A # de Hijo: ____________________________________________________________

CHOOSE ONE OPTION:
_____ If I lose my case and am going to be removed, I would like to take my child with me.
_____ If I lose my case and am going to be removed, I do NOT want to take my child with me.
_____ I do not have a lawyer, and I want to talk with a lawyer before deciding whether I want
my child removed with me.

Certificate of Service
I hereby certify that this form was served by me at________________________
(Location)

on ___________________________ on _____________________________, and the contents of this
(Name of Alien)

(Date of Service)

notice were read to him or her in the __________________________ language.
(Language)

___________________________________ __________________________________________
Name and Signature of Officer

Name or Number of Interpreter (if applicable)