Sensitive (when completed)

Australian Government

Department of Immigration and Border Protection

This document may contain ‘personal identifiers’ and ‘personal information’ as defined under the Migration Act 1958 or Australian Citizenship Act 2007, and can only be used for purposes under these Acts.

Sensitive (when completed)

REQUEST FOR REMOVAL FROM AUSTRALIA

(for use with a New Zealand citizen whose Special Category (TY444) visa was cancelled under subsection 501(3A) of the Migration Act 1958 and who has an un-finalised

application for revocation)

I am an unlawful non-citizen and I request that the Department of Immigration and Border Protection (DIBP) remove me from Australia in accordance with s198(1) of the Migration Act 1958 (the Act), which states that an officer must remove as soon as reasonably practicable an unlawful non-citizen who asks the Minister, in writing, to be so removed.

Removee name: DOB: 

1 I am aware that if I am removed from Australia, I will not be able to be granted a further Special Category (TY444) visa unless the Minister revokes the decision to cancel my visa and I have not re-offended since making an application for revocation.

Yes No

2 I understand that I will incur a debt for the cost of my removal from Australia and the non-repayment of this debt will restrict my ability to obtain most visas, other than a Special Category (TY444) visa.

Yes No

3 I understand that my unfinalised application for revocation of the cancellation decision will continue to be considered after my removal from Australia.

Yes No

4 I understand that if I have an unfinalised application for revocation of the cancellation decision and I wish to be removed from Australia, it is my responsibility to provide DIBP with valid contact details to enable DIBP to fully consider my application and to notify me of the outcome.

Yes No

5 I understand that the Australian government is not responsible for any costs associated with the cancellation including any costs of return arrangements should my revocation application be successful and I choose to return to Australia.

Yes No

Sensitive (when completed)

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Sensitive (when completed)

If you have questions about departing Australia, please speak with your case manager or your legal representative/ migration agent.

Signature:

Name:

Date of Birth:

Citizenship:

Preferred Destination:

Centre ID Number (if applicable):

Date:

DIBP Officer signature:

Interpreter signature (if applicable):

Name: Name:

Position: TIS Number:

6 If I have a legal representative, I have discussed my decision to request removal from Australia with my legal representative.

If “No”, I give permission for DIBP to notify my legal representative of my decision to request removal.

Yes

Yes

No

No

N/A

7 An interpreter has assisted me to understand and complete this form.

Yes No

Not required

8 I have read / had explained to me information in this form and the attachments (if relevant) and I wish to be removed as soon as reasonably practicable.

Yes No

Sensitive (when completed)

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Sensitive (when completed)

If this Request for Removal form is being signed by an unaccompanied minor, the Independent Observer witness must sign below: Independent observer signature:

Name:

ATTACHMENT(S) PROVIDED TO REMOVEE: (delete if not applicable)