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Departure Form

I certify that I am departing the U.S. and have no intention to return to Cal State L.A. or another U.S. school in the next 5 months. I understand my departure date will be submitted to SEVIS and I will not be eligible to re-enter the U.S. on my current SEVIS I-20/DS-2019. It is my responsibility to notify IPS staff of any changes to my immigration situation.

This form means that you are leaving the USA and NOT coming back

Information

Family/Last *
First Name *
Middle Name
CIN / ELP ID
SEVIS Number *
Date Departing *

Reason for departure *

	Completion of program or Optional Practical Training (F-1)/Academic Training (J-1) You must depart the U.S. within 60 days from your completion date or the end of the Optional Practical Training period(F-1). J-1 students must depart within 30 days from the completion of the program or expiration of the Academic Training. Date of completion or end of OPT:
	Early termination from Optional Practical Training (F-1)/Academic Training (J-1) You must depart the U.S. within 15 days from your last day of employment. Last date of employment:
	Early withdrawal from Cal State L.A. or English Language Program - with IPS approval You must depart the U.S. within 15 days of last class attended. Date of last class you attended: If you want to come back, you will have to make a new application and pay the application fee and the SEVIS I-901 fee.

Agreement *

I certify that provided information is correct to the best of my knowledge.