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Fillable Printable Form I-817

Fillable Printable Form I-817

Form I-817

Form I-817

Form I-817 12/23/16 NPage 1 of 12
For USCIS Use Only
Application for Family Unity Benefits
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-817
OMB No. 1615-0005
Expires 10/31/2017
Remarks
From / / /
To / / /
Action Block
Sent
Received
Relocated
Fee Stamp
Resubmitted
Returned
Initial Application
Valid
ApprovedDenied
From / / /
To / / /
Request for Extension
Valid
ApprovedDenied
Part 1. Information About You (Person
Requesting Family Unity Benefits)
2.a.Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c.Middle Name
Provide any other names you have used since birth, including
maiden names, and nicknames.
3.a.
Family Name
(Last Name)
3.b.
Given Name
(First Name)
3.c.
Middle Name
4.a.
Family Name
(Last Name)
4.b.
Given Name
(First Name)
4.c.
Middle Name
10.Country of C
itizenship or Nationality
9.Country
of Birth
8.Gender MaleFemale
ZIP Code11.f.State
City or Town
11.e.
11.d
U.S. Mailing Address
11.a.In Care of Name
Street Number
and Name
11.b.
11.c.Apt.Flr.Ste.
START HERE - Type or print in black ink.
To be completed
by an attorney or
BIA-accredited
representative (if any).
Select this box if
Form G-28 is
attached.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
USCIS Online Account Number (if any)7.
Alien Registration Number (A-Number) (if any)1.
A-
NOTE: You must reside and file Form I-817 while in the United States.
5.Date of Birth (mm/dd/yyyy)
Other Information
U.S. Social Security Number (if any)6.
Your Full Name
Other Names Used
Form I-817 12/23/16 NPage 2 of 12
Part 1. Information About You (Person
Requesting Family Unity Benefits) (continued)
Biographic Information
Part 2. Basis For Application
1.a.
On May 5, 1988, I was the spouse of an alien who
was legalized under section 245A of the Immigration
Nationality Act (INA).
1.b.
On May 5, 1988, I was the unmarried child under 21
years of age of an alien who was legalized under
section 245A of the INA.
I am applying for Family Unity benefits because: (Select
only one box)
13.
14.
Height
16.Weight
FeetInches
15.
Pounds
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select onlyone box)
Race (Select allapplicable boxes)
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Asian
Black or African American
BlackBrown
Maroon
Pink
HazelGreen
Blue
17.
Eye Color (Select only one box)
Unknown/Other
Gray
White
Hair Color (Select only one box) 18.
Black
BrownRed
Unknown/Other
Sandy
Gray
BlondBald (No hair)
1.g.
I am the spouse of a person who is eligible for and
has filed or adjusted status under section 1104 of
Public Law (P.L.) 106-5534, the Legal Immigration
Family Equality (LIFE) Act. I entered the United
States on or before December 1, 1988, and resided
in the United States on that date.
NOTE: To be eligible for Immigration Act of 1990
(IMMACT 90) Family Unity Program benefits, your
qualifying spouse or parent must have maintained his or her
status as a legalized alien or as a U.S. citizen, if he or she
naturalized. If deceased, he or she must have maintained
status until his or her death. For LIFE Act Family Unity, your
spouse or parent must be eligible for adjustment or have
adjusted status under section 1104 of the LIFE Act. If you
previously qualified for LIFE Act Family Unity, you may be
eligible to apply for IMMACT 90 Family Unity Program
Benefits.
2.a.
Initial Family Unity benefits under section 301 of
IMMACT 90.
2.d.
An extension of Family Unity benefits under section
1504 of the LIFE Act Amendments.
2.c.
Initial Family Unity benefits under section 1504 of
the LIFE Act Amendments.
2.b.
An extension of Family Unity benefits under section
301 of IMMACT 90.
I am requesting: (Select only one box)
1.f.
On May 5, 1988, I was the unmarried child under
21 years of age of a person who adjusted status
under section 202 of the Immigration Reform and
Control Act of 1986 (Cuban/Haitian Adjustment).
1.h.
I am the unmarried child under 21 years of age of
a person who had filed an adjustment of status
application or adjusted status under section 1104
of P. L. 106-5534, the LIFE Act. I entered the
United States on or before December 1, 1988, and
resided in the United States on that date.
1.e.
On May 5, 1988, I was the spouse of a legalized
alien who adjusted status under section 202 of the
Immigration Reform and Control Act of 1986
(Cuban/Haitian Adjustment).
On December 1, 1988, I was the spouse of an alien
who was legalized as a Special Agricultural Worker
under section 210 of the INA.
1.c.
1.d.
On December 1, 1988, I was the unmarried child
under 21 years of age ofan alien who was a legalized
alien as a Special Agricultural Worker under section
210 of the INA.
U.S. Physical Address
12.c.
12.d.
12.a.
12.b.
City or Town
State
12.e.
ZIP Code
Street Number
and Name
Apt.Flr.Ste.
Form I-817 12/23/16 NPage 3 of 12
4.Date of Birth (mm/dd/yyyy)
U.S. Social Security Number (if any)7.
A-Number (if any)5.
8.Gender
MaleFemale
9.Class of Admission (visitor, student, EWI, etc.)
USCIS Online Account Number (if any)6.
U.S. Physical Address for Your Spouse or Parent
10.c.
10.d.
City or Town
State
10.e.
ZIP Code
Street Number
and Name
10.a.
10.b.Apt.Flr.Ste.
Marital Status13.
MarriedDivorced
Provide the following information about you and your spouse.
14.a.Number of times you have been married (including current
marriage)
14.b.Number of times your spouse has been married (including
spouse's current marriage)
Complete Only if You Are Applying Based on a
MaritalRelationship or You Were Previously
Married
If currently married, provide the following information about
your marriage.
15.a.
15.b.
Date of Marriage (mm/dd/yyyy)
City or Town
15.c.State
Country15.e.
15.d.Province
15.g.We are:
15.h.If you selected "Not living together," (select only one box):
Living together
My spouse has died
We are separated
We are divorced
Not living together
15.f.Type of Ceremony:
ReligiousCivilNone
A-
2.a.Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c.Middle Name
Other Names Used(Including maiden name, nicknames, etc.)
3.a.Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c.Middle Name
WidowedSeparated
Information About Your Spouse or Parent
Provide the following information about the legalized alien
through whom you are claiming your eligibility.
1.a.Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.Middle Name
If you need extra space to complete Part 3., use the space
provided in Part 9. Additional Information
Part 3. Information About Your Relationship
Daytime Telephone Number (if any)11.
Email Address (if any)12.
Information About Your Prior Marriage
Provide the following information about your prior marriages
(if any).
16.a.Family Name
(Last Name)
16.b. Given Name
(First Name)
16.c.
Middle Name
17.a.Date of Marriage (if any) (mm/dd/yyyy)
Place of Marriage
Form I-817 12/23/16 NPage 4 of 12
Part 3. Information About Your Relationship
(continued)
City or Town
17.c.State
Country17.e.
17.d.Province
17.b.
17.g.
State17.h.
City or Town
17.f.Date of Termination (mm/dd/yyyy)
Province17.i.
17.j.Country
17.k.Reason for Termination
Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 9. Additional Information.)
Divorce Death Annulment
Province19.i.
State19.h.
19.j.Country
19.k.Reason for Termination
Divorce
DeathAnnulment
Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 9. Additional Information.)
19.g.
City or Town
NOTE: If you were previously married, you must complete
Part 3.
, Item Numbers 13. - 19.k.
of this application; complete
all requested information about your prior marriages; and select
the box in Item Number 20. indicating that it is complete.
20.
I have completed Part 3., Item Numbers 13. - 19.k.,
information about my prior marriages (if any).
Information About Your Spouse's Prior Spouse
Provide the following information about your current spouse's
prior marriages(if any).
18.a.Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c.Middle Name
19.a.Date of Marriage (if any) (mm/dd/yyyy)
Place of Prior Marriage
Place of Termination
City or Town
19.c.State
19.b.
Place of Marriage
Country19.e.
19.d.Province
19.f.Date of Termination (mm/dd/yyyy)
Place of Termination
Complete Only if You Are Applying Based on a
Child/Parent Relationship
Biological father who was not married to my mother
when I was born
Indicate how your parent is related to you (Select only one box)
Biological mother
Biological father who was married to my mother
when I was born
21.a.
21.b.
21.c.
Stepparent - based on marriage to my parent which
occurred before my 18th birthday
21.d.
Adoptive parent (select only one box):
A.The adoption occurred before my 16th birthday.
B.My adoptive parent had legal custody of me
on May 5, 1988 or December 1, 1988, (as
appropriate), and I resided with him or her for
two years prior to that date.
Yes
NoYes
No
21.e.
Form I-817 12/23/16 NPage 5 of 12
Part 3. Information About Your Relationship
(continued)
22.a.
Provide the following information about your marital status.
Married
SeparatedWidowed
Single, Never MarriedDivorced
Marital Status
Provide the following information.
23.a.Date of Marriage (mm/dd/yyyy)
23.b.City or Town
23.c.State
Country23.e.
23.d.Province
23.f.Type of ceremony:Religious
CivilNone
23.g.We are:
Living togetherNot living together
23.h.If you selected "Not living together," (Select only one box):
My spouse has died
We are separated
We are divorced
Part 4. Other Information
1.
Have you EVER applied before for the Family Unity
Program?
NoYes
If you answered "Yes," provide the following information.
2.a.Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c.Middle Name
Name Under Which You Applied
2.d.
2.e.
City or Town
2.f.Date Filed (mm/dd/yyyy)
2.g.
U.S. Citizenship and Immigration Services (USCIS) (or
former Immigration and Naturalization Service (INS))
action taken on case
State
ApprovedDenied
3.a.At the time of your last entry into the United States, you
(Select only one box):
Were inspected and admitted
Were inspected and paroled
Entered without inspection
3.b.Date of Last Arrival (mm/dd/yyyy)
Form I-94 Arrival-Departure Record Number3.c.
Place of Marriage
If divorced or widowed, provide the following information.
24.b.City or Town
24.c.State
Country24.e.
24.d.Province
24.a.Date of Marriage (mm/dd/yyyy)
Place Marriage Ended
Place Where Application Was Filed
Passport Number3.d.
Travel Document Number3.e.
3.f.
Country of Issuance for Passport or Travel Document
3.g.
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Current or Most Recent Immigration Status
3.h.
3.i.Date Status Expires (mm/dd/yyyy)
Date Continuous U.S. Residence Began (mm/dd/yyyy)3.j.
Form I-817 12/23/16 NPage 6 of 12
Part 4. Other Information (continued)
Provide the U.S. address where you lived on May 5, 1988 (INA
245Aor or Cuban Haitian Adjustment Act) or December 1,
1988 (INA section 210 or LIFE Act).
Street Number
and Name
4.a.
4.b.Apt.Flr.Ste.
If you are submitting separate applications for Family Unity
benefits at this time for other relatives, provide the following
information about those other relatives.
4.c.
4.d.
City or Town
State
4.e.
ZIP Code
5.a.
Family Name
(Last Name)
5.b.
Given Name
(First Name)
5.c.
A-Number (if any)5.d.
5.e.Relationship to Applicant
Middle Name
A-
NOTE: If you need more space to complete an answer in Item
Numbers 5.a. - 24.f., use Part 9. Additional Information.
6.a.Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c.
A-Number(if any)6.d.
6.e.Relationship to Applicant
Middle Name
A-
7.a.Family Name
(Last Name)
7.b. Given Name
(First Name)
7.c.
A-Number(if any)7.d.
7.e.Relationship to Applicant
Middle Name
A-
8.a.Family Name
(Last Name)
8.b. Given Name
(First Name)
8.c.
A-Number (if any)8.d.
8.e.Relationship to Applicant
9.a.Family Name
(Last Name)
9.b. Given Name
(First Name)
9.c.
A-Number(if any)9.d.
9.e.Relationship to Applicant
Middle Name
Middle Name
A-
A-
10.a.
Family Name
(Last Name)
10.b.
Given Name
(First Name)
10.c.
A-Number(if any)
10.d.
10.e.Relationship to Applicant
Middle Name
A-
List all absences from the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Form I-817,
whichever date is later.
11.a.
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
12.b.
12.a.
11.b.
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
13.b.
13.a.
14.b.
14.a.
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Form I-817 12/23/16 NPage 7 of 12
Part 4. Other Information (continued)
15.b.
15.a.
16.b.
16.a.
17.b.
17.a.
List all residences in the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Family Unity
application (Form I-817), whichever date is later.
18.c.City or Town
18.d.
18.f.
State
FromTo
Present
Dates of Residence (mm/dd/yyyy)
18.e.ZIP Code
Street Number
and Name
18.a.
18.b.Apt.
Flr.Ste.
Current Residence
19.c.City or Town
19.d.
19.f.
State
FromTo
19.e.ZIP Code
Street Number
and Name
19.a.
19.b.Apt.Flr.Ste.
Previous Residence 1
20.c.City or Town
20.d.
20.f.
State20.e.ZIP Code
Street Number
and Name
20.a.
20.b.Apt.Flr.Ste.
Previous Residence 2
FromTo
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
Return Date (mm/dd/yyyy)
Departure Date (mm/dd/yyyy)
Dates of Residence (mm/dd/yyyy)
Dates of Residence (mm/dd/yyyy)
21.c.City or Town
Street Number
and Name
21.a.
21.b.Apt.Flr.Ste.
Previous Residence 3
21.d.
21.f.
State21.e.ZIP Code
FromTo
22.c.City or Town
22.d.
22.f.
State22.e.ZIP Code
Street Number
and Name
22.a.
22.b.Apt.Flr.Ste.
Previous Residence 4
FromTo
23.c.City or Town
23.d.State23.e.ZIP Code
Street Number
and Name
23.a.
23.b.Apt.Flr.Ste.
23.f.
Previous Residence 5
FromTo
Dates of Residence (mm/dd/yyyy)
Dates of Residence (mm/dd/yyyy)
Dates of Residence (mm/dd/yyyy)
Form I-817 12/23/16 NPage 8 of 12
Part 4. Other Information (continued)
NOTE: If you need more space to complete an answer in Item
Numbers 5.a. - 24.f., use Part 9. Additional Information.
Answer Item Numbers 25.a. - 38. If you answer “Yes” to
ANY of the questions, use the space provided in Part 9.
Additional Information to provide an explanation.
25.e.Limiting or denying any person's ability to exercise
religious beliefs?
25.a.Acts involving torture or genocide?
Have you EVER ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:
25.b.Killing any person?
25.c.Intentionally and severely injuring any person?
25.d.Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes
No
YesNo
Yes
No
YesNo
NoYes
Have you EVER:
26.a.
Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, self-
defense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
26.b.Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
YesNo
NoYes
27.
Have you EVER been a member of, assisted in, or
participated
in any group, unit or organization of any kind
in which you or other persons used any type of weapon
against any person or threatened to do so?
YesNo
28.
Have you EVER
assisted or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
29.Have you EVER received any type of military,
paramilitary, or weapons training?
No
YesNo
Yes
24.c.City or Town
24.d.
24.f.
State
Dates of Residence
24.e.ZIP Code
Street Number
and Name
24.a.
24.b.Apt.Flr.Ste.
(mm/dd/yyyy)
Previous Residence 6
FromTo
30.b.
Been a representative of a terrorist organization or a
member of an organization which you knew or should have
known is a terrorist organization?
Have you EVER in the United States or Abroad:
30.a.Engaged in, conspired to engage in, or intended to engage
in a terrorist activity with intent to cause death or serious
bodily harm?
NoYes
31.
Have you EVER e
ngaged in any activity to violate any
law of the United States related to espionage or sabotage
or to violate or evade any law prohibiting the export from
the United States of goods, technology, or sensitive
information?
YesNo
NoYes
32.a.
Been convicted by a final judgment of a particularly
serious crime?
33.
Have you EVER
been convicted of any offenses for
which the aggregate sentences were five or more years
of confinement?
Have you EVER
been ordered deported, excluded, or
removed from the United States as you were inadmissible
at the time of entry or of adjustment of status, or violated
status?
34.
YesNo
No
YesNo
Yes
32.b.Participated in any other criminal activity which
endangers public safety or national security of the
United States?
NoYes
Have you EVER:
Have you
EVER been convicted of a felony crime of
violence that has an element of or attempted use of
physical force against another individual in the course of
committing the offense?
35.
NoYes
36.
Have you EVER
engaged in genocide, or ordered, incited,
assisted or otherwise participated in the persecution of
any person because of race, religion, national origin,
membership in a particular social group, or political
opinion?
YesNo
Form I-817 12/23/16 NPage 9 of 12
Part 4. Other Information (continued)
Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature
NOTE: Read the information on penalties in the Penalties
section of the Form I-817 Instructions before completing this
part.
I have requested the services of and consented to
2.
who is is not an attorney or accredited
representative, preparing this application for me. This
person who assisted me in preparing my application
has reviewed the Acknowledgement of Appointment
at USCIS Application Support Center with me, and
I understand the ASC Acknowledgement.
,
The interpreter named in Part 6. has also read to me
every question and instruction on this application, as
well as my answer to every question, in
1.b.
a language in which I am fluent. I understand every
question and instruction on this application as
translated to me by my interpreter, and have provided
complete, true, and correct responses in the language
indicated above. The interpreter named in Part 6. has
also read the Acknowledgement of Appointment at
USCIS Application Support Center to me, in the
language in which I am fluent, and I understand this
Application Support Center (ASC) Acknowledgement
as read to me by my interpreter.
,
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and have read and
understand every question and instruction on this
application, as well as my answer to every question. I
have read and understand the Acknowledgement of
Appointment at USCIS Application Support
Center.
Applicant's Statement
5.
Applicant's Email Address (if any)
Applicant's Mobile Telephone Number (if any)4.
Applicant's Daytime Telephone Number3.
Applicant's Contact Information
Have you EVER
committed a serious nonpolitical crime
outside the United States before you arrived in the United
States?
37.
NoYes
YesNo
Have you EVER
been convicted of a felony or three or
more misdemeanors in the United States?
38.
I also understand that when I sign my name, provide my
fingerprints, and am photographed at the USCIS ASC, I will be
re-affirming that I willingly submit this application; I have
reviewed the contents of this application; all of the information
in my application and all supporting documents submitted with
my application were provided by me and are complete, true, and
correct; and if I was assisted in completing this application, the
person assisting me also reviewed this Acknowledgement of
Appointment at USCIS Application Support Center with me.
By signing here, I declare under penalty of perjury that I
have reviewed and understand my application, petition, or
request as identified by the receipt number displayed on the
screen above, and all supporting documents, applications,
petitions, or requests filed with my application, petition, or
request that I (or my attorney or accredited representative)
filed with USCIS, and that all of the information in these
materials is complete, true, and correct.
understand that the purpose of a USCIS ASC appointment is
for me to provide my fingerprints, photograph, and/or
signature and to re-affirm that all of the information in my
application is complete, true, and correct and was provided by
me. I understand that I will sign my name to the following
declaration which USCIS will display to me at the time I
provide my fingerprints, photograph, and/or signature during
my ASC appointment.
I,
,
Acknowledgement of Appointment at USCIS
Application Support Center
Form I-817 12/23/16 NPage 10 of 12
Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature (continued)
Applicant'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 and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
I certify, under penalty of perjury, that the information in my
application and any document submitted with my application
were provided by me and are complete, true, and correct.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
Applicant's Signature
6.a.
6.b.Date of Signature (mm/dd/yyyy)
Applicant's Signature
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, your application may be denied.
Interpreter's Full Name
1.a.Interpreter's Family Name (Last Name)
1.b.Interpreter's Given Name (First Name)
Interpreter's Business or Organization Name (if any)2.
Part 6. Interpreter's Contact Information,
Certification, and Signature
Provide the following information concerning the interpreter.
Interpreter's Mailing Address
3.c.City or Town
3.d.State3.e. ZIP Code
3.f.
Postal Code3.g.
Province
3.h.Country
Street Number
and Name
3.a.
3.b.
Apt.Flr.Ste.
Interpreter's Daytime Telephone Number
5.
4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
Interpreter's Certification
I certify that:
I am fluent in English and , which
is the same language provided in Part 5., Item Number 1.b.;
I have read the Acknowledgement of Appointment at USCIS
Application Support Center to the applicant in the same
language provided in Part 5., Item Number 1.b.
The applicant has also informed me that he or she understands
the ASC Acknowledgement and that by appearing for a USCIS
ASC biometric services appointment and providing his or her
fingerprints, photograph, and/or signature, he or she is
re-affirming that the contents of this application and all
supporting documentation are complete, true, and correct.
Interpreter's Signature
6.a.
6.b.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
The applicant has informed me that he or she understands every
instruction and question on the application, as well as the
answer to every question, and the applicant verified the
accuracy of every answer; and
I have read to this applicant every question and instruction on
this application, as well as the answer to every question, in the
language provided in Part 5., Item Number 1.b.; and
Form I-817 12/23/16 NPage 11 of 12
Part 7. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Application, If Other Than the
Applicant
Preparer's Full Name
Provide the following information concerning the preparer.
1.a.Preparer's Family Name (Last Name)
1.b.Preparer's Given Name (First Name)
Preparer's Business or Organization Name (if any)2.
Preparer's Mailing Address
3.c.City or Town
3.d.State3.e. ZIP Code
3.f.
Postal Code3.g.
Province
3.h.Country
Street Number
and Name
3.a.
3.b.
Apt.Flr.Ste.
Preparer's Contact Information
Preparer's Daytime Telephone Number
6.
4.
Preparer's Email Address (if any)
Preparer's Fax Number (if any)5.
Preparer's Statement
I am an attorney or accredited representative and
my representation of the applicant in this case
extends does not extendbeyond the
preparation of this application.
I am not an attorney or accredited representative
but have prepared this application on behalf of the
applicant and with the applicant's consent.
NOTE: If you are an attorney or accredited
representative whose representation extends
beyond preparation of this application you must
submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited
Representative, with this application.
7.a.
7.b.
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this application on behalf of, at the
request of, and with the express consent of the applicant. I
completed this application based only on responses the
applicant provided to me. After completing the application, I
reviewed it and all of the applicant's responses with the
applicant, who agreed with every answer on the application.
If the applicant supplied additional information concerning a
question on the application, I recorded it on the application. I
have also read the Acknowledgement of Appointment at
USCIS Application Support Center to the applicant and the
applicant has informed me that he or she understands the ASC
Acknowledgement.
Preparer's Signature
Preparer's Signature8.a.
8.b.Date of Signature (mm/dd/yyyy)
Part 8. Signature for Placement On Employment
Authorization Document
Provide your signature below. This signature will be scanned
and duplicated for placement on your Employment Authorization
Document.When signing, make sure that no part of your
signature goes outside the lines of the box.
Signature
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