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Fillable Printable Form I-918 Supplement A

Fillable Printable Form I-918 Supplement A

Form I-918 Supplement A

Form I-918 Supplement A

Form I-918 Supplement A 02/07/17 N
Page 1 of 12
To be completed by an
attorney or accredited
representative (if any).
For
USCIS
Use
Only
Action Block
Receipt
U.S.
Embassy
Consulate
Validity Dates (mm/dd/yyyy)
To: / / /
From: / / /
Wait Listed
Stamp NumberDate (mm/dd/yyyy)
Remarks
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
Form I-918
OMB No. 1615-0104
Expires 02/28/2019
Supplement A, Petition for Qualifying Family Member
of U-1 Recipient
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in black or blue ink.
Part 1. Family Member's Relationship To You
(Principal)
Part 2. Information About You (Principal)
NOTE: The recipient of the U-1 nonimmigrant classification is referred to as the "principal." His or her family members are referred
to as "derivatives." The principal should complete Supplement A.
ChildSpouse
Unmarried sibling under 18 years of age
The family member that I am filing for is my:
Status of your Form I-918
Parent
1.
1.a.Family Name
(Last Name)
1.b.Given Name
(First Name)
1.c.
Middle Name
3.
5.
A-
2.
ApprovedPending
Part 3. Information About Your Qualifying
Family Member (Derivative)
1.a.Family Name
(Last Name)
1.b.Given Name
(First Name)
1.c.
Middle Name
Other Names Used (Include maiden name, nicknames, and
aliases, if applicable)
Alien Registration Number (A-Number) (if any)
Date of Birth (mm/dd/yyyy)
Other Information
2.a.Family Name
(Last Name)
2.b.Given Name
(First Name)
2.c.
Middle Name
USCIS Online Account Number (if any)4.
NOTE:If you need extra space to complete this section, use the
space provided in Part 11. Additional Information.
Residence or Intended Residence in the United
States
3.a.Street Number
and Name
3.c.City or Town
3.d.State3.e. ZIP Code
3.b.Flr.Ste.Apt.
Form I-918 Supplement A 02/07/17 N
Page 2 of 12
Country of Citizenship or Nationality
7.
Part 3. Information About Your Qualifying
Family Member (The Derivative) (continued)
11.
Form I-94 Arrival-Departure Record Number
8.
9.
10.
Passport Number
12.
Travel Document Number
13.
17.
18.
Part 4. Additional Information About Your
Qualifying Family Member
Provide the date of last entry, place of last entry, and current
immigration status for your family member if he or she is
currently in the United States.
1.b.
1.c.
1.d.
Place of Last Entry into the United States
Current Immigration Status
State
City or Town
2.b.
2.c.
2.e.
Place of Last Entry into the United States
State
City or Town
Provide the date of entry, place of entry, and status at entry
for your family member's last entry if he or she has
previously traveled to the United States but is not currently
in the United States.
2.d.Date Authorized Stay Expired (mm/dd/yyyy)
Status at the Time of Entry (for example, F-1 student,
B-2 tourist, entered without inspection)
14.
Country of Issuance for Passport or Travel Document
5.
Date of Birth (mm/dd/yyyy)
Other Information About Qualifying Family
Member
6.
Country of Birth
Safe Mailing Address (if other than Residence)
15.
Date of Issuance for Passport or Travel Document
(mm/dd/yyyy)
Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
16.
A-Number (if any)
A-
U.S. Social Security Number (if any)
USCIS Online Account Number (if any)
Married
Widowed
Single
Marital Status
Divorced
GenderMaleFemale
1.a.
Date of Last Entry into the United States (mm/dd/yyyy)
2.a.Date of Last Entry into the United States (mm/dd/yyyy)
Street Number
and Name
4.b.
4.d.City or Town
4.e.State4.f.ZIP Code
4.c.
Ste.Flr.Apt.
In Care Of Name 4.a.
Province
4.g.
Postal Code4.h.
4.i.Country
Form I-918 Supplement A 02/07/17 N
Page 3 of 12
Part 4. Additional Information About Your
Qualifying Family Member (continued)
If your family member was previously married, list the
names of your family member's prior spouses and the dates
his or her marriages were terminated. You must attach
documents such as divorce decrees or death certificates.
5.a.Family Name
(Last Name)
5.b.Given Name
(First Name)
5.c.
Middle Name
Date Marriage Ended (mm/dd/yyyy)5.d.
Safe Foreign Address Where You Want Notification Sent
(if other than U.S. Consulate, Pre-Flight Inspection, or
Port-of-Entry)
7.a.Your family member was or is in immigration
proceedings.
8.
YesNo
Your family member would like an Employment
Authorization Document.
Other Information
If you answered "Yes," select the type of proceedings. If your
family member was in proceedings in the past and is no longer
in proceedings, provide the date of action. If your family
member is currently in proceedings, type or print “Current” in
the appropriate date field. Select all applicable boxes. Use the
space provided in Part 11. Additional Information to provide
an explanation.
NOTE: If you answered "Yes," submit Form I-765,
Application for Employment Authorization Document,
separately. If your family member is living outside the
United States, he or she is not eligible to receive
employment authorization until he or she is lawfully
admitted to the United States. Do not file Form I-765 for
a family member living outside the United States.
If your family member is outside the United States, provide
the U.S. Consulate or inspection facility
or a safe foreign
mailing address you want notified if this supplement is
approved.
Pre-Flight Inspection
U.S. Consulate
Type of Office (Select only one box):
Port-of-Entry
3.a.
3.d.
3.b.
3.c.
City or Town
State
Country
6.a.Family Name
(Last Name)
6.b.Given Name
(First Name)
6.c.
Middle Name
How did the marriage end?6.f.
6.e.Where did the marriage end?
Date Marriage Ended (mm/dd/yyyy)6.d.
5.e.Where did the marriage end?
How did the marriage end?5.f.
Street Number
and Name
4.a.
4.b.
Ste.Flr.Apt.
Province
4.d.
Postal Code4.e.
4.f.Country
City or Town4.c.
7.c.
Exclusion Date (mm/dd/yyyy)
Exclusion Proceedings
Removal Date (mm/dd/yyyy)
Removal Proceedings
7.b.
Rescission Proceedings7.e.
Judicial Date (mm/dd/yyyy)
7.f.
Rescission Date (mm/dd/yyyy)
Judicial Proceedings
Deportation Proceedings
Deportation Date (mm/dd/yyyy)
7.d.
NoYes
Form I-918 Supplement A 02/07/17 N
Page 4 of 12
Part 5. Processing Information
Been placed in an alternative sentencing or a rehabilitative
program (for example, diversion, deferred prosecution,
withheld adjudication, deferred adjudication)?
Been arrested, cited, or detained by any law enforcement
officer (including Department of Homeland Security
(DHS), former Immigration and Nationalization Service
(INS), and military officers) for any reason?
Committed a crime or offense for which he or she has not
been arrested?
Been convicted of a crime or offense (even if the violation
was subsequently expunged or pardoned)?
Been charged with committing any crime or offense?
Has your family member EVER:
Received a suspended sentence, been placed on probation,
or been paroled?
NOTE: Answering "Yes" does not necessarily mean that U.S.
Citizenship and Immigration Services (USCIS) will deny your
Supplement A, Petition for Qualifying Family Member of U-1
Recipient.
NOTE: If you answer “Yes” to ANY question in Part 5.,
provide an explanation in the space provided in Part 11.
Additional Information.
Been the beneficiary of a pardon, amnesty, rehabilitation,
or other act of clemency or similar action?
Exercised diplomatic immunity to avoid prosecution for a
criminal offense in the United States?
Been held in jail or prison?
Answer the following questions about the family member for
whom you are filing this supplement. For the purposes of this
supplement, you must answer "Yes" to the following questions,
if applicable, even if your family member's records were sealed
or otherwise cleared or if anyone, including a judge, law
enforcement officer, or attorney, told your family member that
he or she no longer has a record.
1.a.
1.e.
1.f.
1.d.
1.c.
1.b.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1.i.
1.g.
1.h.
YesNo
YesNo
YesNo
Information About Arrests, Citations, Detentions, or Charges
Outcome or disposition (for example, no charges filed,
charges dismissed, jail, probation)
Where was your family member arrested, cited, detained, or
charged?
2.c.
2.f.
Country
2.d.
City or Town
2.e.
State
Outcome or disposition (for example, no charges filed,
charges dismissed, jail, probation)
3.a
3.c.
Date of arrest, citation, detention, or charge (mm/dd/yyyy)3.b.
3.f.
Country
3.d.
City or Town
3.e.
State
Why was your family member arrested, cited, detained, or
charged?
2.a
Date of arrest, citation, detention, or charge (mm/dd/yyyy)2.b.
Where was your family member arrested, cited, detained, or
charged?
Why was your family member arrested, cited, detained, or
charged?
Form I-918 Supplement A 02/07/17 N
Page 5 of 12
Part 5. Processing Information (continued)
5.a.
Has your family member EVER committed, planned or prepared,
participated in, threatened to, attempted to, conspired to commit,
gathered information for, or solicited funds for any of the
following:
The use of any biological agent, chemical agent, nuclear
weapon or device, explosive, or other weapon or
dangerous device, with intent to endanger, directly or
indirectly, the safety of one or more individuals or to
cause substantial damage to property?
Hijacking or sabotage of any conveyance (including an
aircraft, vessel, or vehicle)?
The use of any firearm with intent to endanger, directly or
indirectly, the safety of one or more individuals or to
cause substantial damage to property?
5.d.
5.e.
YesNo
YesNo
YesNo
Assassination?5.c.
YesNo
5.b.Seizing or detaining, and threatening to kill, injure, or
continue to detain, another individual in order to compel a
third person (including a governmental organization) to
do or abstain from doing any act as an explicit or implicit
condition for the release of the individual seized or
detained?
YesNo
4.d.Illicitly trafficked in any controlled substance or knowingly
assisted, abetted, or colluded in the illicit trafficking of any
controlled substance?
YesNo
4.c.Knowingly encouraged, induced, assisted, abetted, or
aided any alien to try to enter the United States illegally?
YesNo
4.b.Engaged in any unlawful commercialized vice, including,
but not limited to, illegal gambling?
YesNo
4.a.
Has your family member EVER:
Engaged in, or does he or she intend to engage in,
prostitution or procurement of prostitution?
YesNo
Has your family member EVER been a member of, solicited
money or members for, provided support for, attended military
training (as defined in section 2339D(c)(1) of Title 18, United
States Code) by or on behalf of, or been associated with any other
group of two or more individuals, whether organized or not,
which has been designated as, or has engaged in or has a
subgroup which has been designated as, or has engaged in:
A terrorist organization under section 219 of the
Immigration and Nationality Act (INA)?
6.a.
YesNo
Hijacking or sabotage of any conveyance (including an
aircraft, vessel, or vehicle)?
6.b.
Yes
No
Espionage?
Has your family member EVER been or does he or she
continue to be a member of the Communist or other
totalitarian party, except when membership was
involuntary?
Solely, principally, or incidentally in any activity related
to espionage or sabotage or to violate any law involving
the export of goods, technology, or sensitive information?
7.c.
8.
YesNo
YesNo
Any unlawful activity, or any activity the purpose of
which is in opposition to, or the control, or overthrow of
the Government of the United States?
YesNo
7.b.
YesNo
Does your family member intend to engage in the United
States in:
7.a.
Soliciting money or members or otherwise providing
material support to a terrorist organization?
6.g.
YesNo
6.f.
YesNo
The use of any biological agent, chemical agent, nuclear
weapon or device, explosive, or other weapon or dangerous
device, with intent to endanger, directly or indirectly, the
safety of one or more individuals or to cause substantial
damage to property?
The use of any firearm with intent to endanger, directly or
indirectly, the safety of one or more individuals or to cause
substantial damage to property?
6.e.
YesNo
Seizing or detaining, and threatening to kill, injure, or
continue to detain, another individual in order to compel a
third person (including a governmental organization) to
do or abstain from doing any act as an explicit or implicit
condition for the release of the individual seized or
detained?
6.c.
YesNo
Assassination?6.d.
YesNo
Form I-918 Supplement A 02/07/17 N
Page 6 of 12
In any way compelled or forced to engage in any kind of
sexual contact or relations?
Displaced or moved from his or her residence by force,
compulsion, or duress?
Has your family member EVER, during the period of
March 23, 1933 to May 8, 1945, in association with either
the Nazi Government of Germany or any organization or
government associated or allied with the Nazi Government
of Germany, ordered, incited, assisted or otherwise
participated in the persecution of any person because of
race, religion, nationality, membership in a particular
social group or political opinion?
Part 5. Processing Information (continued)
9.
YesNo
YesNo
YesNo
YesNo
Intentionally killed, tortured, beaten, or injured?
Has your family member EVER been present or nearby when
any person was:
12.a.
12.b.
12.c.
NOTE: If you answered "Yes" to any question in Item
Numbers 10.a. - 10.g., please describe the circumstances in the
spaces provided in Part 11. Additional Information.
Has your family member EVER advocated that another
person commit any of the acts described in Item
Numbers 10.a. - 10.g., urged, or encouraged another
person, to commit such acts?
YesNo
11.
Limiting or denying any person's ability to exercise
religious beliefs?
YesNo
10.e.
The persecution of any person because of race, religion,
national origin, membership in a particular social group,
or political opinion?
YesNo
10.f.
Displacing or moving any person from their residence by
force, threat of force, compulsion, or duress?
YesNo
10.g.
Engaging in any kind of sexual conduct or relations with
any person who was being forced or threatened?
YesNo
10.d.
Intentionally and severely injuring any person?
YesNo
10.c.
Acts involving torture or genocide?
YesNo10.a.
Has your family member EVER ordered, incited, called for,
committed, assisted, helped with, or otherwise participated in any
of the following:
Killing any person?
YesNo10.b.
Has your family member EVER:
Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
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 other insurgent organization?
13.a.
13.b.
YesNo
YesNo
Served in, been a member of, assisted in, or participated
in any group, unit, or organization of any kind in which
you or other persons transported, possessed, or used any
type of weapon?
13.c.
YesNo
NOTE: If you answered "Yes" to any question in Item
Numbers 13.a. - 13.c., please describe the circumstances in
Part 11. Additional Information.
Has your family member EVER had removal, exclusion,
rescission, or deportation proceedings initiated against
him or her?
17.
YesNo
Recruited, enlisted, conscripted, or used any person under 15
years of age to serve in or help an armed force or group?
Is your family member NOWin removal, exclusion,
rescission, or deportation proceedings?
16.
YesNo
Used any person under 15 years of age to take part in
hostilities, or to help or provide services to people in
combat?
15.b.
Yes
No
15.a.
Yes
No
NOTE: If you answered "Yes" to any question in Item
Numbers 14.a. - 14.c., please describe the circumstances in
Part 11. Additional Information.
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?
14.c.
YesNo
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
14.b.
Received any type of military, paramilitary, or weapons
training?
14.a.
YesNo
Has your family member EVER:
Has your family member EVER:
Form I-918 Supplement A 02/07/17 N
Page 7 of 12
Part 5. Processing Information (continued)
Is your family member NOW under a final order or civil
penalty for violating section 274C of the INA (producing
and/or using false documentation to unlawfully satisfy a
requirement of the INA)?
22.
YesNo
Has your family member EVER been granted voluntary
departure by an immigration officer or an immigration
judge and failed to depart within the allotted time?
21.
YesNo
Does your family member NOW have a communicable
disease of public health significance?
29.a.
29.b.
29.c.
Does your family member NOW have or has your family
member EVER had a physical or mental disorder and
behavior (or a history of behavior that is likely to recur)
associated with the disorder which has posed or may pose
a threat to the property, safety, or welfare of yourself or
others?
Is your family member NOW or has your family member
EVER been a drug abuser or drug addict?
YesNo
YesNo
YesNo
Has your family member EVER detained, retained, or
withheld the custody of a child, having a lawful claim to
United States citizenship, outside the United States from a
United States citizen granted custody?
Does your family member plan to practice polygamy in
the United States?
Has your family member EVER entered the United States
as a stowaway?
26.
27.
YesNo
YesNo
Yes
No
Has your family member EVER, by fraud or willful
misrepresentation of a material fact, sought to procure or
procured a visa or other documentation, for entry into the
United States or any immigration benefit?
23.
Yes
No
Has your family member EVER been denied a visa or
denied admission to the United States?
Has your family member EVER been ordered to be
removed, excluded, or deported from the United States?
19.
20.
YesNo
YesNo
Has your family member EVER been removed, excluded,
or deported from the United States?
18.
YesNo
Part 6. Information About Your Qualifying
Family Member's Spouse and/or Children
9.a.Family Name
(Last Name)
9.b.Given Name
(First Name)
9.c.
Middle Name
10.
11.Country of Birth
12.Relationship
Date of Birth (mm/dd/yyyy)
Middle Name5.c.
Given Name
(First Name)
5.b.
Family Name
(Last Name)
5.a.
Relationship8.
Country of Birth7.
6.
Date of Birth (mm/dd/yyyy)
2.
3.Country of Birth
4.Relationship
Date of Birth (mm/dd/yyyy)
Provide the following information about your family member's
spouse and/or children. If you need extra space to complete this
section, use the space provided in Part 11. Additional
Information.
1.a.Family Name
(Last Name)
1.b.Given Name
(First Name)
1.c.
Middle Name
Has your family member EVER been a J nonimmigrant
exchange visitor who was subject to the 2-year foreign
residence requirement and not yet complied with that
requirement or obtained a waiver of such?
25.
YesNo
Has your family member EVER left the United States to
avoid being drafted into the U.S. Armed Forces or U.S.
Coast Guard?
24.
YesNo
28.
Form I-918 Supplement A 02/07/17 N
Page 8 of 12
Part 7. Petitioner's Statement, Contact
Information, Declaration, and Signature
NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
NOTE: Read the Penalties section of the Form I-918
Instructions before completing this part.
1.a.
I can read and understand English, and I have read and
understand every question and instruction on this
supplement and my answer to every question.
The interpreter named in Part 9. read to me every
question and instruction on this supplement and my
answer to every question in
1.b.
a language in which I am fluent, and I understood
everything.
,
Petitioner's Statement
prepared this supplement for me based only upon
information I provided or authorized.
At my request, the preparer named in Part 10.,
2.
,
Petitioner's Daytime Telephone Number3.
Petitioner's Contact Information
4.Petitioner's Mobile Telephone Number (if any)
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
I further authorize release of information contained in this
supplement, 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.
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.
Petitioner's Declaration and Certification
5.
Petitioner's Email Address (if any)
1) I provided or authorized all of the information
contained in, and submitted with, my supplement;
2) I reviewed and understood all of the information in,
and submitted with, my supplement; and
3) All of this information was complete, true, and
correct at the time of filing.
I certify, under penalty of perjury, that all of the information in
my supplement and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
supplement, and that all of this information is complete, true,
and correct.
Petitioner's Signature
Petitioner's Signature (sign in ink)6.a.
6.b.Date of Signature (mm/dd/yyyy)
NOTE TO ALL PETITIONERS: If you do not completely
fill out this supplement or fail to submit required documents
listed in the Instructions, USCIS may deny your supplement.
Part 8. Qualifying Family Member's Statement,
Contact Information, Declaration, and Signature
NOTE: Read the Penalties section of the Form I-918
Instructions before completing this part.
1.a.
I can read and understand English, and I have read and
understand every question and instruction on this
supplement and my answer to every question.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Qualifying Family Member's Statement
The interpreter named in Part 9. read to me every
question and instruction on this supplement and my
answer to every question in
1.b.
a language in which I am fluent, and I understood
everything.
,
At my request, the preparer named in Part 10.,2.
,
prepared this supplement for me based only upon
information I provided or authorized.
Form I-918 Supplement A 02/07/17 N
Page 9 of 12
4.Qualifying Family Member's Mobile Telephone Number
(if any)
5.
Qualifying Family Member's Email Address (if any)
Qualifying Family Member's Daytime Telephone Number3.
Qualifying Family Member's Contact Information
Part 8. Qualifying Family Member's Statement,
Contact Information, Declaration, and Signature
(continued)
Qualifying Family Member'sDeclaration and
Certification
NOTE TO ALL QUALIFYING FAMILY MEMBERS: If
you do not completely fill out this supplement or fail to submit
required documents listed in the Instructions, USCIS may deny
your supplement.
Qualifying Family Member's Signature (sign in ink)6.a.
6.b.Date of Signature (mm/dd/yyyy)
Qualifying Family Member's Signature
I further authorize release of information contained in this
supplement, 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. Any
disclosure shall be in accordance with 8 U.S.C. section 1367
and 8 CFR 214.14(e).
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 understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1) I provided or authorized all of the information
contained in, and submitted with, my supplement;
2) I reviewed and understood all of the information in,
and submitted with, my supplement; and
3) All of this information was complete, true, and
correct at the time of filing.
Part 9. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
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.
I certify, under penalty of perjury, that all of the information in
my supplement and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
supplement, and that all of this information is complete, true,
and correct.
Interpreter's Contact Information
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.
Ste.Flr.
Apt.
Interpreter's Daytime Telephone Number
6.
4.
Interpreter's Email Address (if any)
Interpreter's Mobile Telephone Number (if any)5.
Form I-918 Supplement A 02/07/17 N
Page 10 of 12
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 7., Item Number
1.b., and Part 8. Item Number 1.b., and I have read to this
petitioner and qualifying family member in the identified
language(s) every question and instruction on this supplement
and the petitioner's and qualifying family member's answer to
every question. The petitioner and qualifying family member
informed me that they understand every instruction, question,
and answer on the supplement, including the Petitioner's
Declaration and Certification and the Qualifying Family
Member's Declaration and Certification, and have verified
the accuracy of every answer.
Part 9. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Signature
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Petition, if
Other Than the Petitioner or Qualifying Family
Member
Preparer's Full Name
Provide the following information about the preparer.
Preparer's Statement
I am an attorney or accredited representative and my
representation of the petitioner and qualifying family
memberin this case extends does not extend
beyond the preparation of this supplement.
I am not an attorney or accredited representative but
have prepared this supplement on behalf of the
petitioner andqualifying family member and with the
petitioner's and qualifying family member's consent.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this supplement, you may be obliged to
submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative,
with this supplement.
7.a.
7.b.
Interpreter's Signature (sign in ink)7.a.
7.b.Date of Signature (mm/dd/yyyy)
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.
Ste.Flr.Apt.
Preparer's Contact Information
Preparer's Daytime Telephone Number
6.
4.
Preparer's Email Address (if any)
Preparer's Mobile Telephone Number (if any)5.
Form I-918 Supplement A 02/07/17 N
Page 11 of 12
Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Petition, if
Other Than the Petitioner or Qualifying Family
Member (continued)
Preparer's Signature
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this supplement at the request of the petitioner and
qualifying family member. The petitioner and qualifying family
member then reviewed this completed supplement and informed
me that they understand all of the information contained in, and
submitted with, this supplement, including the Petitioner's
Declaration and Certification, and the Qualifying Family
Member's Declaration and Certification, and that all of this
information is complete, true, and correct. I completed this
supplement based only on information that the petitioner and
qualifying family member provided to me or authorized me to
obtain or use.
Preparer's Signature (sign in ink)8.a.
8.b.Date of Signature (mm/dd/yyyy)
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