Fillable Printable Form I-694

Form I-694

Form I-694 12/23/16 N Page 1 of 6

Notice of Appeal of Decision Under INA Section 210 or 245A

of the Immigration and Nationality Act

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-694

OMB No. 1615-0034

Expires: 03/31/2018

START HERE - Type or print in black ink.►

For

USCIS

Use

Only

Action Block Fee Stamp

Family Name (Last Name) Given Name (First Name)

Middle Name

Part 1. Information About You (Appellant)

Full Legal Name

Any Other Names Used2.

Family Name (Last Name) Given Name (First Name) Middle Name

In Care Of Name

U.S. Mailing Address

City or Town

State ZIP Code

Street Number and Name Flr.Ste.Apt.

Is your current U.S. mailing address the same as your U.S. physical address?

If you answered "No," provide your U.S. physical address in Item Number 5.

NoYes

Number

7. U.S. Social Security Number (if any)6. Alien Registration Number (A-Number) (if any)

►

A-

►

U.S. Physical Address

Street Number and Name

City or Town State ZIP Code

Flr.Ste.Apt.

Number

USCIS Online Account Number (if any)8.

►

Form I-694 12/23/16 N Page 2 of 6

Part 2. Application Information

Part 3. Reason for Appeal

The appeal must include a statement explaining any error or conclusion of law in the decision being appealed or any erroneous

statement of fact stated in the decision. Please provide an explanation. If you need additional space to complete this section, use

the space provided in Part 7. Additional Information.

Is your written brief attached?

If you answered "No," select a response in Item Number 2.

NoYes

Your appeal is based on an application for which of the following?

Receipt Number (if any)

Date of Decision (mm/dd/yyyy)3.

Permanent Residence

(Form I-698)

Temporary Residence

(Form I-687)

Waiver of Grounds of Inadmissibility

(Form I-690)

I waive the right to submit a written brief or statement. I will submit a brief within 30 calendar days.

Form I-694 12/23/16 N Page 3 of 6

At my request, the preparer named in Part 6.,

prepared this form for me based only upon information I provided or authorized.

Appellant's Statement Regarding the Preparer2.

Appellant's Signature Date of Signature (mm/dd/yyyy)6.

Appellant's Signature

The interpreter named in Part 5. read to me every question and instruction on this form and my answer to

, a language in whichevery question in

I am fluent and I understood everything.

Appellant's Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may

require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of

my records that USCIS may need to determine my eligibility for the immigration benefit I seek.

I can read and understand English, and I have read and understand every question and instruction on this form and my

answer to every question.

Part 4. Appellant's Statement, Contact Information, Certification, and Signature

Appellant's Statement Regarding the Interpreter1.

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

NOTE: Read the Penalties section of the Form I-694 Instructions before completing this part.

Appellant's Email Address (if any)5.

Appellant's Daytime Telephone Number 3. 4. Appellant's Mobile Telephone Number (if any)

Appellant's Contact Information

NOTE TO ALL APPELLANTS: If you do not completely fill out this form or fail to submit required documents listed in the

Instructions, USCIS may deny your benefit.

Appellant's Statement

I certify, under penalty of perjury, that I provided or authorized all of the information in this form, I understand all of the information

contained in, and submitted with, this form, and that all of this information is complete, true, and correct.

Interpreter's Full Name

Provide the following information about the interpreter.

Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name)

Part 5. Interpreter's Contact Information, Certification, and Signature

Interpreter's Business or Organization Name (if any)

Form I-694 12/23/16 N Page 4 of 6

Interpreter's Mailing Address

City or Town

State ZIP Code

Street Number and Name Flr.Ste.Apt.

Postal Code CountryProvince

Number

in Part 4., Item B. in Item Number 1., and I have read to this appellant in the identified language every question and instruction on

this form and his or her answer to every question. The appellant informed me that he or she understands every instruction, question,

and answer on the form, including the Appellant's Certification, and has verified the accuracy of every answer.

4. Interpreter's Daytime Telephone Number

Interpreter's Email Address (if any)

Interpreter's Contact Information

Interpreter's Certification

I am fluent in English and , which is the same language provided

I certify, under penalty of perjury, that:

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Interpreter's Signature

5. Interpreter's Mobile Telephone Number (if any)

Part 6. Contact Information, Declaration, and Signature of the Person Preparing This Form, if Other

Than the Appellant

Provide the following information about the preparer.

Preparer's Family Name (Last Name) Preparer's Given Name (First Name)1.

Preparer's Full Name

Preparer's Business or Organization (if any)2.

Part 5. Interpreter's Contact Information, Certification, and Signature (continued)

Form I-694 12/23/16 N Page 5 of 6

City or Town State ZIP Code

Street Number and Name Flr.Ste.Apt.

Postal Code CountryProvince

Preparer's Mailing Address

Number

Preparer's Daytime Telephone Number 4.

Preparer's Email Address (if any)6.

5. Preparer's Mobile Telephone Number (if any)

Preparer's Contact Information

I am an attorney or accredited representative and my representation of the appellant in this case

extends does not extend beyond the preparation of this form.

Preparer's Certification

I am not an attorney or accredited representative but have prepared this form on behalf of the

appellant and with the appellant's consent.

By my signature, I certify, under penalty of perjury, that I prepared this form at the request of the appellant. The appellant then

reviewed this completed form and informed me that he or she understands all of the information contained in, and submitted with, his

or her form, including the Appellant's Certification, and that all of this information is complete, true, and correct. I completed this

form based only on information that the appellant provided to me or authorized me to obtain or use.

Preparer's Statement

Preparer's Signature Date of Signature (mm/dd/yyyy)

Preparer's Signature

NOTE: If you are an attorney or accredited representative whose representation extends beyond

preparation of this form, you may be obliged to submit a completed Form G-28, Notice of Entry

of Appearance as Attorney or Accredited Representative, with this form.

Part 6. Contact Information, Declaration, and Signature of the Person Preparing This Form, if Other

Than the Appellant (continued)

Form I-694 12/23/16 N Page 6 of 6

Part 7. Additional Information

If you need extra space to provide any additional information within this form, use the space below. If you need more space than what

is provided, you may make copies of this page to complete and file with this form or attach a separate sheet of paper. Type or print

your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which

your answer refers; and sign and date each sheet.

A-Number (if any) ►

A-

Page Number

Part Number Item Number

Family Name (Last Name) Given Name (First Name) Middle Name

B. C.

Page Number

Part Number

Item Number4. B. C.

Page Number

Part Number Item Number

5. B. C.

Page Number

Part Number Item Number

6. B. C.