INTENT TO LEAVE THE COUNTRY ALERT
RUN DATE: MMDDYY FO CODE: XXX
SSN: 999-00-9999 ALIEN ID NUMBER: AXXXXXXXXX
DHS NAME: AAAAAAAAAA A AAAAAAAAAAAAA
PLANNED DEPARTURE DATE: MMDDCCYY
DOB: MMDDCCYY
SSR NAME: AAAAAAAAAAAAAAA AAAAAAAAAAAAAAA
AAAAAAAAAAAAAAA
Address - xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Telephone Number – (999-999-9999)
COUNTRY OF BIRTH: XX LENGTH OF STAY: XXXXXXXXXXXX
FOR INSTRUCTIONS, SEE POMS SI 02310.017.