OMB#ll25-0001

U.S. Department of Justice Application for Cancellation of Removal and Adjustment

Executive Office for Immigration Review of Status for Certain Nonpermanent Residents

PLEASE READ ADVICE AND INSTRUCTIONS Fee Stamp (Official Use Only)
BEFORE FILLING IN FORM

PLEASE TYPE OR PRINT

1) My present true name is: (Last, First, Middle) 2) Alien Registration (or “A”) Number(s):
Perez Martinez, Jonhy Gerardo 201990877
3) My name given at birth was: (Last, First, Middle) 4) Birth Place: (City andCountry)
Perez Martinez, Jonhy Gerardo Mexico
5) Date of Birth: (Month, Day, Year) 6) Gender: ✔ Male Female 7) Height: 8) Hair Color: 9) Eye Color:
12/25/1983 5'7" Black Black
10) Current Nationality and Citizenship: 11) Social Security Number: 12) Home Phone Number: 13) Work Phone Number:
Mexico (404) 784-8510
14) I currently reside at: 15) I have been known by these additional name(s):
5365 Newport Bay Passage
Alpharetta GA 30005

16) I have resided in the following locations in the United States: (List PRESENT ADDRESS FIRST, and work back in time for at least 10
years.)
Street and Number - Apt. or Room # - City or Town - State - Zip Code Resided From: Resided To:
(Month, Day, Year) (Month, Day, Year)

5365 Newport Bay Passage , Alpharetta, Georgia, 30005, United States 06/2018 PRESENT
3201 Henderson Mill Rd, Apt 27A, Atlanga, Georgia, 30329, United States 07/2011 06/2018
2180 Rocky Ridge Rd, Hoover, Alabama, 35216, United States 12/2006 07/2011
3621 Snapwood Rd, Hoover, Alabama, 35216, United States 10/2003 12/2006

17) I, the undersigned, hereby request that my removal be cancelled under the provisions of section 240A(b) of the Immigration and Nationality
Act (INA). I believe that I am eligible for cancellation of removal because: (Check all that apply.)

✔ My removal would result in exceptional and extremely unusual hardship to my:

UNITED STATES LAWFUL PERMANENT
CITIZEN RESIDENT
✔ ✔
spouse, who is a
father, who is a
mother, who is a
✔ child/children, who is/are a ✔

With the exception of absences described in question #23, I have resided in the United States since: 2003
(Month, Day, Year)

Please continue answers on a separate sheet as needed. Form EOIR-42B

(1) Revised
 PART 3 - INFORMATION ABOUT YOUR PRESENCE IN THE UNITED STATES
18) I first arrived in the United States under the name of: (Last, First, Middle) 19) I first arrived in the United States on: (Month, Day, Year)

Perez Martinez, Jonhy Gerardo 2003

20) Place or port of first arrival: (Place or Port, City, and State)

Southern Border
21) I: was inspected and admitted.
I entered using my Lawful Permanent Resident card which is valid until .
Category on Lawful Permanent Resident card . (Month, Day, Year)
I entered using a visa which is valid until .
✔ (Specify Type of Visa) (Month, Day, Year)
was not inspected and admitted.
✔ I entered without documents. Explain: EWI .
✔ I entered without inspection. Explain: EWI .
Other. Explain: .
22) I applied on for additional time to stay and it was granted on
(Month, Day, Year) (Month, Day, Year)
and valid until , or denied on .
(Month, Day, Year) (Month, Day, Year)

23) Since the date of my first entry, I departed from and returned to the United States at the following places and on the following dates:
(Please list all departures regardless of how briefly you were absent from the United States.)
If you have never departed from the United States since your original date of entry, please mark an X in this box: ✔
Port of Departure (Place or Port, City and State) Departure Date (Month, Day, Year) Purpose of Travel Destination

1 Inspected and Admitted?

Port of Return (Place or Port, City and State) Return Date (Month, Day, Year) Manner of Return
Yes No
Port of Departure (Place or Port, City and State) Departure Date (Month, Day, Year) Purpose of Travel Destination

2 Inspected and Admitted?

Port of Return (Place or Port, City and State) Return Date (Month, Day, Year) Manner of Return
Yes No

24) Have you ever departed the United States: a) under an order of deportation, exclusion, or removal?. ..................................... Yes ✔ No
b) pursuant to a grant of voluntary departure?. ....................................................... Yes ✔ No

PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued on page 3)
25) I am not married: 26) If married, the name of my spouse is: (Last, First, Middle) 27) My spouse’s name before marriage was:
I am married: ✔ Gazzo Doig, Francesca
28) The marriage took place in: (City and Country) 29) Date of marriage: (Month, Day, Year)

Atlanta, GA, USA 02/14/2020

30) My spouse currently resides at: 31) Place and date of birth of my spouse: (City & Country; Month, Day, Year)

Apt. number and/or in care of

5365 Newport Bay Passage 32) My spouse is a citizen of: (Country)
Number and Street
Alpharetta GA 30005
City or Town State/Country Zip Code
USA
33) If your spouse is other than a native born United States citizen, answer the following:
He/she arrived in the United States at: (Place or Port, City and State) .

He/she arrived in the United States on: (Month, Day, Year) 06/2001 .

His/her alien registration number(s) is: A# .

He/she was naturalized on: (Month, Day, Year) 09/24/2016 at Atlanta, GA .
(City and State)

34) My spouse ✔ - is - is not employed. If employed, please give salary and the name and address of the place(s) of employment.
Full Name and Address of Employer Earnings Per Week
(Approximate)
J&F Interior Inc, 5365 Newport Bay Passage, Alpharetta, GA, 30005 $ 500
$
$
Please continue answers on a separate sheet as needed. Form EOIR-42B
( Revised
 PART 4 - INFORMATION ABOUT YOUR MARITAL STATUS AND SPOUSE (Continued)

35) I - have ✔ - have not been previously married: (If previously married, list the name of each prior spouse, the dates on which each mar-
riage began and ended, the place where the marriage terminated, and describe how each marriage ended.)
Name of prior spouse: (Last, First, Middle) Date marriage began: Place marriage ended: Description or manner of how marriage was
Date marriage ended: (City and Country) terminated or ended:

36) My present spouse ✔ - has - has not been previously married: (If previously married, list the names of each prior spouse, the dates on
which each marriage began and ended, the place where the marriage terminated, and describe how each marriage ended.)

Name of prior spouse: (Last, First, Middle) Date marriage began: Place marriage ended: Description or manner of how marriage was
Date marriage ended: (City and Country) terminated or ended:
Andronic, Alin Eduardo 2016 Atlanta, GA, USA Divorce
05/07/2019
37) Have you been ordered by any court, or are otherwise under any legal obligation, to provide child support and/or spousal maintenance as a
result of a separation and/or divorce? Yes ✔ No

PART 5 - INFORMATION ABOUT YOUR EMPLOYMENT AND FINANCIAL STATUS

38) Since my arrival into the United States, I have been employed by the following named persons or firms: (Please begin with present employment and
work back in time. Any periods of unemployment or school attendance should be specified. Attach a separate sheet for additional entries if necessary .)
Full Name and Address of Employer Earnings Per Week Type of Work Employed From: Employed To:
(Approximate) Performed (Month, Day, Year) (Month, Day, Year)
J&F Interior Inc, 5363 Newport Bay Passage, Alpharetta, Project
$ 1500 2015 PRESENT
GA 30005 Manager

39) If self-employed, describe the nature of the business, the name of the business, its address, and net income derived therefrom:

40) My assets (and if married, my spouse’s assets) in the United States and other countries, not including clothing and household necessities, are:
Self Jointly Owned With Spouse
Cash, Stocks, and Bonds................................ $ 40,000 Cash, Stocks, and Bonds. ...............................$ 70,000
Real Estate...................................................... $ 0 Real Estate...................................................... $ 800,000
Auto (dollar value minus amount owed)....... $ 40,000 Auto (dollar value minus amount owed)........$ 60,000
Other (describe on line below)....................... $ 0 Other (describe on line below). ...................... $
TOTAL $ 80,000 TOTAL $ 930,000

41) I - have ✔ - have not received public or private relief or assistance (e.g.,Welfare, Unemployment Benefits, Medicaid, TANF, AFDC,
etc.). If you have, please give full details including the type of relief or assistance received, date for which relief or assistance was received, place,
and total amount received during this time:

42) Please list each of the years in which you have filed an income tax return with the Internal Revenue Service:

Please continue answers on a separate sheet as needed. Form EOIR-42B

( ) Revised
 PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued on page 5)
43) I have 2 (Number of) children. Please list information for each child below, include assets and earnings information for
children over the age of 16 who have separate incomes:
Name of Child: (Last, First, Middle) Citizen of What Country: Now Residing At: (City and Country) Immigration Status
Child’s Alien Registration Number: Birth Date: (Month, Day, Year) Birth Place: (City and Country) of Child
Perez, Brielle Juliett USA Alpharetta, GA, USA USC
A#: 11/26/2018 GA, USA
Estimated Total of Assets: $ 0 Estimated Average Weekly Earnings: $ 0
Perez, Miranda Rose USA Alpharetta, GA, USA USC
A#: 12/17/2020 GA, USA
Estimated Total of Assets: $ 0 Estimated Average Weekly Earnings: $ 0

A#:
Estimated Total of Assets: $ Estimated Average Weekly Earnings: $

44) If your application is denied, would your spouse and all of your children accompany you to your:
If you answered “No” to any of the
Country of Birth - Yes ✔ No responses, please explain:

Country of Nationality - Yes ✔ No

Country of Last Residence - Yes ✔ No

45) Members of my family, including my spouse and/or child(ren) - have ✔ - have not received public or private relief or assistance (e.g.,
Welfare, Unemployment Benefits, Medicaid, TANF, AFDC, etc.). If any member of your immediate family has received such relief or assistance, please
give full details including identity of person(s) receiving relief or assistance, dates for which relief or assistance was received, place, and
total amount received during this time:

46) Please give the requested information about your parents, brothers, sisters, aunts, uncles, and grandparents, living or d eceased. As to residence,
show street address, city, and state, if in the United States; otherwise show only country:

Name: (Last, First, Middle) Citizen of What Country: Relationship to Me: Immigration Status
Alien Registration Number: Birth Date: (Month, Day, Year) Birth Place: (City and Country) of Listed Relative
Perez Roldan, Gerardo Mexico Father Citizen of Mexico
A#: 10/03/1959 Mexico
Complete Address of Current Residence, if Living:
Mexico

Martinez Cruz, Rosa Mexico Mother Citizen of Mexico

A#:
Complete Address of Current Residence, if Living:

Please continue answers on a separate sheet as needed. Form EOIR-42B

(4) Revised
 PART 6 - INFORMATION ABOUT YOUR FAMILY (Continued)
IF THIS APPLICATION IS BASED ON HARDSHIP TO A PARENT OR PARENTS, QUESTIONS 47-50 MUST BE ANSWERED.
47) If your parent is not a citizen of the United States, give the date and place of arrival in the United States including full details as to the date,
manner, and terms of admission into the United States:

48) My father - is - is not employed. If employed, please give salary and the name and address of the place(s) of employment.
Full Name and Address of Employer Earnings Per Week
(Approximate)

49) My mother - is - is not employed. If employed, please give salary and the name and address of place(s) of employment.
Full Name and Address of Employer Earnings Per Week
(Approximate)

50) My parent’s assets in the United States and other countries not including clothing and household necessities are:
Assets of father consist of the following: Assets of mother consist of the following:
Cash, Stocks, and Bonds................................ $ Cash, Stocks, and Bonds. .............................. $
Real Estate...................................................... $ Real Estate......................................................$
Auto (dollar value minus amount owed)....... $ Auto (dollar value minus amount owed)........$
Other (describe on line below)....................... $ Other (describe on line below). ......................$
TOTAL $ TOTAL $

PART 7 - MISCELLANEOUS INFORMATION (Continued on page 6)

51) I - have ✔ - have not entered the United States as a crewman after June 30, 1964.

52) I - have ✔ - have not been admitted as, or after arrival in the United States acquired the status of, an exchange alien.

53) I - have ✔ - have not submitted address reports as required by section 265 of the Immigration and Nationality Act.

54) I ✔ - have - have never (either in the United States or in any foreign country) been arrested, summoned into court as a defendant, con-
victed, fined, imprisoned, placed on probation, or forfeited collateral for an act involving a felony, misdemeanor, or breach of any public law or
ordinance(including, but not limited to, traffic violations or driving incidents involving alcohol). (If answer is in the affirmative, please give a
brief description of each offense including the name and location of the offense, date of conviction, any penalty imposed, any sentence imposed,
and the time actually served. You are required to submit documentation of any such occurrences.)
Traffic violation.

55) Have you ever served in the Armed Forces of the United States? Yes ✔ No. If “Yes” please state branch (Army, Navy, etc.) and
service number:

Place of entry on duty: (City and State)

Date of entry on duty: (Month, Day, Year) Date of discharge: (Month, Day, Year)

Type of discharge: (Honorable, Dishonorable, etc.)

I served in active duty status from: (Month, Day, Year) to (Month, Day, Year)

56) Have you ever left the United States or the jurisdiction of the district where you registered for the draft to avoid being drafted into the military or
naval forces of the United States?
Yes ✔ No
Please continue answers on a separate sheet as needed. Form EOIR-42B
(5) Revised
 PART 7 - MISCELLANEOUS INFORMATION (Continued)
57) Have you ever deserted from the military or naval forces of the United States while the United States was at war? Yes ✔ No

58) If male, did you register under the Military Selective Service Act or any applicable previous Selective Service (Draft) Laws? Yes ✔ No
If “Yes,” please give date, Selective Service number, local draft board number, and your last draft classification:

59) Were you ever exempted from service because of conscientious objection, alienage, or any other reason? Yes ✔ No

60) Please list your present or past membership in or affiliation with every political organization, association, fund, foundation, party, club, society,
or similar group in the United States or any other place since your 16 th birthday. Include any foreign military service in this part. If none, write
“None.” Include the name of the organization, location, nature of the organization, and the dates of membership.

Member From: Member To:

Name of Organization Location of Organization Nature of Organization (Month, Day, Year) (Month, Day, Year)

61) Have you ever:

Yes ✔ No been ordered deported, excluded, or removed?

Yes ✔ No overstayed a grant of voluntary departure from an Immigration Judge or the Department of Homeland Security (DHS),
formerly the Immigration and Naturalization Service (INS)?
Yes ✔ No failed to appear for removal or deportation?
62) Have you ever been:

Yes ✔ No a habitual drunkard?

Yes ✔ No one whose income is derived principally from illegal gambling?
Yes ✔ No one who has given false testimony for the purpose of obtaining immigration benefits?
Yes ✔ No one who has engaged in prostitution or unlawful commercialized vice?
Yes ✔ No involved in a serious criminal offense and asserted immunity from prosecution?
Yes ✔ No a polygamist?
Yes ✔ No one who brought in or attempted to bring in another to the United States illegally?
Yes ✔ No a trafficker of a controlled substance, or a knowing assister, abettor, conspirator, or colluder with others in any such
controlled substance offense (not including a single offense of simple possession of 30 grams or less of marijuana)?
Yes ✔ No inadmissible or deportable on security-related grounds under sections 212(a)(3) or 237(a)(4) of the INA?
Yes ✔ No one who has ordered, incited, assisted, or otherwise participated in the persecution of an individual on account of his or
herrace, religion, nationality, membership in a particular social group, or political opinion?
Yes ✔ No a person previously granted relief under sections 212(c) or 244(a) of the INA or whose removal has previously been
cancelled under section 240A of the INA?

If you answered “Yes” to any of the above questions, explain:

Please continue answers on a separate sheet as needed. Form EOIR-42B

(6) Revised
 PART 7 - MISCELLANEOUS INFORMATION (Continued)
63) Are you the beneficiary of an approved visa petition? Yes ✔ No
If yes, can you arrange a trip outside the United States to obtain an immigrant visa? ✔ Yes No If no, please explain:
I have a pending I-130 petition through my USC spouse. Once approved, I intend to file an I-601A waiver and consular
process.

64) Name of School, Type of School, Degree Earned / Date (if any), Location (City/Country), Attended From (MM/YY) To (MM/YY)

65) The following certificates or other supporting documents are attach

PART 8 - SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT

(Read the following information and sign below)

I declare that I have prepared this application at the request of the person named in Part 1, 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 applica-
tion was read to the applicant in a language the applicant speaks fluently for verification before he or she signed the applica- tion
in my presence. I am aware that the knowing placement of false information on the Form EOIR-42B may subject me to civil
penalties under 8 U.S.C.§1324c.

Signature of Preparer: Print Name: Date:

Emily A. Lund
Daytime Telephone#: Address of Preparer: (Number and Street, City, State, Zip Code)
P.O. Box 501359, Atlanta, Georgia, 31150, United States
(404) 860-1263

Please continue answers on a separate sheet as needed. Form EOIR-42B

(7) Revised
 PART 9 - SIGNATURE

APPLICATION NOT TO BE SIGNED BELOW UNTIL APPLICANT APPEARS BEFORE

AN IMMIGRATION JUDGE

I swear or affirm that I know the contents of this application that I am signing, including the attached documents and supplements, and that they
are all true to the best of my knowledge, taking into account the correction(s) numbered to , if any, that were made by me or at
my request.

(Signature of Applicant or Parent or Guardian)

Subscribed and sworn to before me by the above-named applicant at

Immigration Judge

Date (Month, Day, Year)

PART 10 - PROOF OF SERVICE

I hereby certify that a copy of the foregoing Form EOIR-42B was: - delivered in person - mailed first class, postage prepaid

on to the Assistant Chief Counsel for the DHS (U.S. Immigration and Customs Enforcement - ICE)
(Month, Day, Year)

at
(Number and Street, City, State, Zip Code)

No service needed. I electronically filed this document, and the opposing party is participating in ECAS.

Signature of Applicant (or Attorney or Representative)

Please continue answers on a separate sheet as needed. Form EOIR-42B

(8) Revised