U.S. Immigration and Customs Enforcement
Enforcement and Removal Operations
Separated Parent’s Removal Form
Purpose: This form is for detained alien parents with administratively final orders of removal who are class
members in the Ms. L. v. I.C.E., No. 18-0428, (S.D. Cal. Filed Feb. 26, 2018) lawsuit. Class members are
entitled to be reunited with their child(ren) and may choose for their child(ren) to accompany them on their
removal or may choose to be removed without their child(ren). Any such decision must be made
affirmatively, knowingly, and voluntarily.
Instructions: This form must be read to the alien parent in a language that he/she understands. The alien
parent should indicate which option he/she is choosing by signing the appropriate box below.
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: ____________________________________________________________
Shelter / Albergue: ____________________________________________________________________

English: I am requesting to reunite with my child(ren) for the purpose of repatriation to my country of
citizenship.
Signature / Firma: ________________________________________________________________________

English: I am affirmatively, knowingly, and voluntarily requesting to return to my country of citizenship
without my minor child(ren) who I understand will remain in the United States to pursue available claims of
relief.
Signature / Firma: ________________________________________________________________________

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)