Sensitive (when completed)

Australian Government
Department of Immigration and Border Protection
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

Yes
from Australia and the non-repayment of this debt will restrict
my ability to obtain most visas, other than a Special Category
(TY444) visa.
3 I understand that my unfinalised application for revocation of
Yes
the cancellation decision will continue to be considered after
my removal from Australia.
4 I understand that if I have an unfinalised application for
Yes
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.

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.

No

Yes

No
No

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)

Sensitive (when completed)

-26 If I have a legal representative, I have discussed my decision to
request removal from Australia with my legal representative.

Yes

No

Yes

No

7 An interpreter has assisted me to understand and complete this

form.

Yes

No

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

If No, I give permission for DIBP to notify my legal

representative of my decision to request removal.

N/A

Not
required
No

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:

Sensitive (when completed)

Sensitive (when completed)

-3If 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)

Sensitive (when completed)