Deferred Action Termination Request Form
Submit your request to terminate deferred action. Please complete all required fields accurately.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reference or Case Number
*
Current Deferred Action Type
*
Please Select
Employment-based
Family-based
Humanitarian
Other
Requested Termination Effective Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Termination
*
Upload Supporting Documentation (if any)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit Request
Submit Request
Should be Empty: