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Fillable Printable Form I-694

Fillable Printable Form I-694

Form I-694

Form I-694

Form I-694 12/23/16 NPage 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 BlockFee Stamp
Family Name (Last Name)Given Name (First Name)
Middle Name
1.
Part 1. Information About You (Appellant)
Full Legal Name
Any Other Names Used2.
Family Name (Last Name)Given Name (First Name)Middle Name
Family Name (Last Name)Given Name (First Name)Middle Name
B.
A.
3.
In Care Of Name
U.S. Mailing Address
City or Town
StateZIP Code
Street Number and NameFlr.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.
4.
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 TownStateZIP Code
Flr.Ste.Apt.
5.
Number
USCIS Online Account Number (if any)8.
Form I-694 12/23/16 NPage 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 providedin Part 7. Additional Information.
Is your written brief attached?
If you answered "No," select a response in Item Number 2.
1.
NoYes
2.
2.
Your appeal is based on an application for which of the following?
1.
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 NPage 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 SignatureDate 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
B.
, 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
A.
Appellant's Statement Regarding the Interpreter1.
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the boxfor 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)
1.
Part 5. Interpreter's Contact Information, Certification, and Signature
Interpreter's Business or Organization Name (if any)
2.
Form I-694 12/23/16 NPage 4 of 6
Interpreter's Mailing Address
3.
City or Town
StateZIP Code
Street Number and NameFlr.Ste.Apt.
Postal CodeCountryProvince
Number
in Part 4., Item B. in ItemNumber 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:
6.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
6.
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 NPage 5 of 6
3.
City or TownStateZIP Code
Street Number and NameFlr.Ste.Apt.
Postal CodeCountryProvince
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 extendbeyond 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.
7.
Preparer's Statement
B.
A.
Preparer's SignatureDate of Signature (mm/dd/yyyy)
8.
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 NPage 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 NumberItem Number
D.
Family Name (Last Name)Given Name (First Name)Middle Name
1.
2.
3.
D.
D.
D.
B.C.
Page Number
Part Number
Item Number4.B.C.
Page Number
Part NumberItem Number
5.B.C.
Page Number
Part NumberItem Number
6.B.C.
A.
A.
A.
A.
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