IN THE MATTER OF NAME: A#: STIPULATED REQUEST FOR FINAL ORDER OF REMOVAL AND WAIVER OF HEARING I, ___________________, Respondent,

herein make the following requests, statements, admissions, and stipulations: 1. I have received a copy of the Notice to Appear (NTA) dated ________, and my, true and correct name is as indicated therein. See attached NTA. I have also received a legal aid list. I have attorney, _____________, who will represent me in this matter. See attached form EOIR-28. 2. I request that my removal proceedings be conducted completely on a written record, without a hearing. I waive all my rights and advisals contained in 8 C.F.R. 88 1240.10, 1240.11 and 1242.15, including my right to have a hearing recorded in full, to be advised by the Immigration Judge of any apparent relief from removal proceedings, to present witnesses and evidence on my behalf, and, if needed, to require the government to prove that I am deportable. 3. I admit all the factual allegations contained in the Notice to Appear, and concede that I am removable as charged. 4. I agree that I am not eligible, or if eligible, I waive my right to apply for relief from removal proceedings. I am not seeking voluntary departure, asylum, adjustment of status, registry, de novo review of a termination of conditional resident status, de novo review of a denial or revocation of temporary protected status, cancellation of removal pursuant to section 240A(a) or (b) of the Immigration & Nationality Act (Act), or any other possible relief under the Act. 5. I consent to the introduction of this Stipulated Request as an exhibit to the record of proceedings. 6. I designate ____________ as my country of choice for my removal.

7. I will accept a written order for my removal to the above country as a final disposition of these removal proceedings, and I waive appeal of the written order for my removal from the United States. 8. I understand that by accepting an order of removal, I give up my right to apply for any relief for which I might have been eligible. I understand that I (am/am not) a permanent resident immigrant. In the case that I am a permanent resident immigrant, I understand that accepting an order of removal terminates my permanent resident status

and invalidates my alien registration receipt card. I also understand that I cannot return to the Unites States legally either for five (5), ten (10), or twenty (20) years without special permission from the Attorney General. See, INA 212(a)(9)(A)(i), (ii). I also understand that returning without proper consent or authorization from the Unites States Government could result in my being removed again or being prosecuted. I understand that prosecution for illegal reentry may result in punishment of up to twenty (20) years in prison. 9. In the event that my removal proceedings are scheduled for a hearing, I waive any right to notice of such hearing. Additionally, I waive my right to be present in person and, I also waive the presence of my attorney who has signed this document along with myself. 10. My attorney has read and explained this entire Stipulated Request to me either in Spanish or in the language that I best know and understand. I fully understand the consequences of this Stipulated Request for removal. I can unequivocally state that I have submitted this Stipulated Request voluntarily, knowingly and intelligently. 11. I certify that all the information I have given in the Stipulated Request is true and correct:

___________________ (Date)

________________________________ (Signature of Respondent)

________________________________ (Printed Name of Respondent)

____________________ (Date)

________________________________ (Signature of Attorney)

________________________________ (Printed Name of Attorney)

____________________ (Date)

________________________________ Assistant District Counsel Department of Homeland Security Immigration & Customs Enforcement