I-600a Toc

Form I-600A, Form

Application for Advance Processing of an Orphan Petition

OMB RIN: 1615-0028

8/26/2014

Reason for Revision: UAA

Location	Current Text	Proposed Text
Page 1, Type or print legibly in black ink.	Type or print legibly in black ink. This application is made by the named prospective adoptive parent for advance processing of an orphan petition.	START HERE - Type or print legibly in black ink. This application is made by a prospective adoptive parent for advance processing of an orphan petition.
Page 1, Block I	6. My telephone number is: (include area code)	[deleted- moved to be in signature section]
Page 1, Block I. Information About Prospective Adoptive Parent	BLOCK 1 – Information About the Prospective Adoptive Parent 1. My name is (Last) (First) (Middle) 2. Other names used (including maiden name if appropriate): 3. I reside in the U.S. at: (C/O if appropriate) (Number and Street) (Apt. No.) (Town or City) (State) (Zip Code) 4. Address abroad (if any): (Number and Street) (Apt. No.) (Town or City) (State) (Zip Code) 7. I am a citizen of the United States through: __ Birth __ Parents __Naturalization If acquired through naturalization, provide the following: Name under which you naturalized: Naturalization certificate number Date of naturalization (mm/dd/yyyy) Place of naturalization If acquired through parentage, have you obtained a certificate in your own name based on that acquisition? No__ Yes__ If not, submit evidence of citizenship. See Page 2 of the instructions. Have you or any person through whom you claimed citizenship ever lost U.S. citizenship? No__ Yes __ (If “Yes,” attach detailed explanation) 8. My marital status is: a. __Married __Widowed __Divorced __Single b. I have been married __ time(s) 9. If you are now married, provide the following information: Date of present marriage (mm/dd/yyyy) Place of present marriage Name of present spouse (Last) (First) (Middle) (Maiden, if any) Date of birth of present spouse (mm/dd/yyyy) Place of birth of present spouse My spouse has been married __ time(s) My spouse resides: __With me __Apart from me (provide address below) Number and Street Apt. No. City State Country	Page 1, Part 1. Information About You (Applicant) … 1. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 2. Other Names You Have Used (including maiden name, nicknames, and aliases, if any) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 3. U.S. Mailing Address (if any) In Care Of Name Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 4. Is your current U.S. mailing address the same as your U.S. physical address? If you answered “No” to Item Number 4., provide your U.S. physical address in Item Number 5. or your address abroad in Item Number 6., as appropriate. 5. U.S. Physical Address (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 6. Address Abroad (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State Province Postal Code Country 7. Date of Birth (mm/dd/yyyy) 8. City/Town/Village of Birth 9. State or Province of Birth 10. Country of Birth 11. Information About U.S. Citizenship A. Are you a citizen of the United States? __Yes __ No NOTE: If you answered “No,” you may NOT file Form I-600A. See the What Are the Eligibility Requirements? section of the Form I-600A instructions for more information. B. How did you acquire your U.S. citizenship? __ Birth __ Parents __Naturalization C. If you acquired your citizenship through your parents, have you obtained a Certificate of Citizenship in your own name? __ Yes __No If “Yes,” provide the following information about your Certificate of Citizenship: Name Under Which the Certificate of Citizenship Was Issued Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Alien Registration Number (A-Number)( if any) Certificate of Citizenship Number Date of Issuance (mm/dd/yyyy) Place of Issuance D. If you acquired your citizenship through naturalization, provide the following information about your Certificate of Naturalization: Name Under Which the Certificate of Naturalization Was Issued Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) A-Number (if any) Certificate of Naturalization Number Date of Naturalization (mm/dd/yyyy) Place of Naturalization 12. Have you, or any person through whom you claimed citizenship, EVER lost U.S. citizenship? __ Yes __ No NOTE: If you answered “Yes,” attach a detailed explanation on 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. 13. What is your marital status? __Married __Widowed __Divorced __Single 14. How many times have you been married (including your current marriage, if applicable)? 15. Date of Current Marriage (if applicable) (mm/dd/yyyy) 16. Place Where Current Marriage Occurred (if applicable) 17. Information About Your Current Spouse (if applicable) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Other Names Your Current Spouse Has Used (including maiden name, nicknames, and aliases, if any) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Date of Birth (mm/dd/yyyy) A-Number (if any) City/Town/Village of Birth State or Province of Birth Country of Birth Spouse’s Immigration Status 18. How many times has your current spouse has been married (including your current marriage, if applicable)? 19. Does your current spouse reside with you? Yes__ No__ If you answered “No,” provide your current spouse’s physical address in Item Number 20. 20. Your Current Spouse’s Physical Address Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country 21. How many persons 18 years of age or older, other than your current spouse (if married), reside with you? If you answered “1” or more, you MUST complete Form I-600A/I-600 Supplement 1, Listing of Adult Member of the Household, for each person. 22. Have you ever previously filed Form I-600A, Form I-600, Petition to Classify Orphan as an Immediate Relative, Form I-800A, Application for Determination of Suitability to Adopt a Child From a Convention Country, or Form I-800, Petition to Classify Convention Adoptee as an Immediate relative? If “Yes,” provide the following: Type of Application/Petition Filed Result- Check the box that best describes the action taken by USCIS and/or U.S. Department of State on your application and/or petition. __ Approved – Approval Date (mm/dd/yyyy): _________ __Denied - Denial Date (mm/dd/yyyy): _________ NOTE: A copy of the denial notice must accompany this application. __Other - Explain____________ A detailed description of any previous Form I-600 or Form I-800 filing that resulted in a disruption prior to finalization of the adoption or that resulted in a completed adoption that was later dissolved either in the United States or abroad.__________________________ NOTE: If you need extra space to complete this question, attach a separate sheet of paper; type or print your A-Number (if any) at the top of each sheet; include the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. [new] Duty of Disclosure You and your spouse (if married), must answer the following questions. See the Duty of Disclosure section in the instructions to Form I-600A concerning your ongoing duty to disclose information in response to these questions. If you or your spouse answer "Yes" to any of these questions, provide a certified copy of the documentation showing the final disposition of each incident which resulted in arrest, indictment, conviction, and/or any other judicial or administrative action and a written statement giving details, including any mitigating circumstances about each arrest, signed by you and/or your spouse (if married) under penalty of perjury under U.S. law. The written statement must show the date of each incident; place incident occurred (city/town, state/province, country); name of police department or other law enforcement administration or other entity involved; date of incarceration and name of facility, if applicable. Provide a description of any type of counseling, rehabilitation, or other information that you and your spouse (if married) would like considered in light of this history on 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. 23. Have you EVER, whether in or outside the United States: A. Been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding traffic violations, but including driving or operating a vehicle while intoxicated or while impaired by or under the influence of alcohol or other intoxicant, even if the record of the arrest, conviction, or other adverse criminal history was expunged, sealed, pardoned, or the subject of any other amelioration? __ Yes __ No B. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? __ Yes __ No C. Received a suspended sentence, been placed on probation or parole, or in an alternative sentencing or rehabilitation program, such as diversion, deferred prosecution, deferred or withheld adjudication, or expungement of a criminal charge? __ Yes __ No D. At any time been the subject of any investigation by any child welfare agency, court, or other official authority in any state or foreign country concerning the abuse or neglect of any child, other than an investigation that has been completed and formally closed based on a finding that the allegation of abuse or neglect was unfounded or unsubstantiated? __ Yes __ No 24. Has your spouse EVER, whether in or outside the United States: A. Been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any law or ordinance, excluding traffic violations, but including driving or operating a vehicle while intoxicated or while impaired by or under the influence of alcohol or other intoxicant, even if the record of the arrest, conviction, or other adverse criminal history was expunged, sealed, pardoned, or the subject of any other amelioration? __ Yes __ No B. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? __ Yes __ No C. Received a suspended sentence, been placed on probation or parole, or in an alternative sentencing or rehabilitation program, such as diversion, deferred prosecution, deferred or withheld adjudication, or expungement of a criminal charge? __ Yes __ No D. At any time been the subject of any investigation by any child welfare agency, court, or other official authority in any state or foreign country concerning the abuse or neglect of any child, other than an investigation that has been completed and formally closed based on a finding that the allegation of abuse or neglect was unfounded or unsubstantiated? __ Yes __ No
		Page 4, Part 2. Information About Your Home Study Preparer and/or Adoption Service Provider 1.Your home study: __IS attached to this Form I-600A. __IS NOT attached to this Form I-600A because of state requirements necessitating review and documentation. The appropriate state authority has indicated that it will submit the home study directly to U.S. Citizenship and Immigration Services (USCIS). (Do not submit your Form I-600A to USCIS until the state authority is ready to send your home study to USCIS.) __Will be submitted within one year from the date of this Form I-600A filing. (If your home study is not received within one year, your Form I-600A application will be denied under 8 CFR 204.3(c)(2) and (h)(5).) Select one of the following options for which you will provide a name, address, and contact information in Item Number 3: __The adoption service provider that is responsible for your home study (i.e., the accredited agency as defined in 22 CFR 96.2, that prepared your home study or reviewed and approved your home study after it was prepared by another authorized home study preparer, or the public domestic authority, as defined in 22 CFR 96.2, that prepared your home study); or __The primary adoption service provider who is responsible in your case, if you have already identified a primary adoption service provider. (A primary adoption service provider is an accredited agency or approved person who is responsible under 22 CFR 96.14 for ensuring the six adoption services defined in 22 CFR 96.2 are provided, supervising and being responsible for supervised providers where used, and developing and implementing a service plan in accordance with 22 CFR 96.44.) Provide the name and contact information of your adoption service provider. Name of Adoption Service Provider Point of Contact Within the Organization Family Name (Last Name) Given Name (First Name) Provider’s Mailing Address Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Provider’s Daytime Telephone Number Provider’s Fax Number (if any) Provider’s Email Address (if any)
Page 2, General Information	Block II. - General Information 10. Name and address of organization or individual assisting you in locating or identifying an orphan. Name of organization or individual: Address of organization or individual: 11. Do you plan to travel abroad to locate or adopt a child? __No __Yes 12. Does your spouse, if any, plan to travel abroad to locate or adopt a child? __No __Yes 13. If the answer to Question 11 or 12 is "Yes," provide the following information, if known: a. Your date of intended departure (mm/dd/yyyy): b. Your spouse's date of intended departure (mm/dd/yyyy): c. Names of city, province, country you are traveling to: 14. Will the child be adopted abroad after having been personally seen and observed by you and your spouse (if married)? 15. Will the preadoption requirements, if any, of the child's proposed State of residence be met prior to or after the child enters the United States? 16. From what country do you plan to adopt, if known? 17. Where do you wish to file your orphan Application? (Complete one of the options below) The USCIS office located at: ____________________________ OR The U.S. Embassy or consulate at: ___________________________ 18. Do you plan to adopt more than one child? __No __Yes If "Yes," how many children do you plan to adopt? __	Page 5, Part 3. General Information (See Part 2.) [Deleted.] [Delete.] [Delete.] 1. Do you or your spouse (if married) plan to travel abroad to locate or adopt a child? __Yes __ No 2. If you answered “Yes” to Item Numbers 1., provide the following information (if available): Your intended departure date (mm/dd/yyyy): Your spouse's intended departure date (mm/dd/yyyy): Place to which you or your spouse (if married) are travelling City or Town Province Country 3. Will you and your spouse (if married) adopt the child abroad after either you or your spouse (if married) have personally seen and observed the child? 4. Provide a written description of the pre-adoption requirements, if any, of the state of the child's proposed residence if you know that the child will be adopted in the United States. Cite any relevant state statutes and regulations, and describe the steps you have already taken or will take to comply with these requirements. Note and explain any pre-adoption requirements that you cannot meet at this time due to operation of state law. NNOTE: If you need extra space to complete this Item Number, attach a separate sheet of paper; type or print your name and Alien Registration Number (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. 5. What is the intended country of adoption (if known)? 6. Where do you wish to file your orphan petition? (Complete one of the options below) The USCIS office located at: ____________________________ OR The U.S. Embassy or U.S. Consulate located at: __________________________ 7. Do you plan to adopt more than one child? __ Yes __ No 8. If you answered "Yes" to Item Number 7., enter the number of children you plan to adopt.
Page 3, Block III-Accommodations for Individuals With Disabilities and Impairments	(Read the information in the instructions before completing this section.)  19. I am requesting an accommodation: 1. Because of my disability(ies) and/or impairment(s). __ No __ Yes 2. For my spouse because of his or her disability(ies) and/or impairment(s). __ No __Yes 3. For my household members because of his or her disability(ies) and/or impairment(s). __ No __ Yes If you answered “Yes,” check any applicable box. Provide information on the disability(ies) and/or impairment(s) for each person: Deaf or hard of hearing and request the following accommodation(s) (if requesting a sign-language interpreter, indicate which language (e.g., American Sign Language)): Blind or sight-impaired and request the following accommodation(s): Other type of disability(ies) and/or impairment(s) (describe the nature of the disability(ies) and/or impairment(s) and accommodation(s) being requested):	Page 5, Part 4. Accommodations for Individuals With Disabilities and/or Impairments Are you requesting an accommodation because of disabilities and/or impairments? __ Yes __ No If you answered “Yes” to Item Number 1., select all applicable boxes below that indicate who has the disabilities and/or impairments. Applicant Spouse Other Household Member If you answered “Yes” to Item Number 1., select all applicable boxes below. Provide information for each person with the disabilities and/or impairments. __ Deaf or hard of hearing and request the following accommodations (If requesting a sign-language interpreter, indicate for which language (e.g., American Sign Language): __Blind or have low vision and request the following accommodations: __Another type of disability and/or impairment. (Describe the nature of the disability and/or impairment and accommodation you are requesting):
Page 4, Certification of Prospective Adoptive Parent	Certification of Prospective Adoptive Parent I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct and that I will care for an orphan/orphans properly if admitted to the United States. (Signature of Prospective Adoptive Parent) (Executed on (Date) Certification of Married Prospective Adoptive Parent Spouse I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct and that my spouse and I will care for an orphan/orphans properly if admitted to the United States. (Signature of Prospective Adoptive Parent Spouse) (Executed on (Date) Signature of Person Preparing Form, If Other Than Applicant I declare that this document was prepared by me at the request of the petitioner and is based entirely on information of which I have knowledge (Signature) (Executed on (Date) Street Address and Room or Suite No./City/State/Zip Code	Page 7, Part 5. Applicant’s Statement, ASC Acknowledgement (if applicable), Certification, Signature, and Contact Information Applicant’s Statement Select the box for either Item Number 1.A. or 1.B. If applicable, select the box for Item Number 2. 1.A. [Check Box] I can read and understand English, and have read and understand each and every question and instruction on this application, as well as my answer to each question. I have read and understand the Acknowledgement of Appointment at USCIS Application Support Center (if applicable). 1.B. [Check Box] The interpreter named in Part 9. has read to me each and every question and instruction on this application, as well as my answer to each question, in [Fillable Field], a language in which I am fluent. I understand each and every question and instruction on this application as translated to me by my interpreter, and have provided complete, true, and correct responses. The interpreter named in Part 9 also has read the Acknowledgement of Appointment at USCIS Application Support Center (if applicable) to me, in the language in which I am fluent, and I understand this ASC Acknowledgement as read to me by my interpreter. 2. [Check Box] I have requested the services of and consented to [Fillable Field], 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 (if applicable) with me and I understand the ASC Acknowledgement. Acknowledgement of Appointment at USCIS Application Support Center (if applicable) I, [Auto-populate Field Applicant Full Name], understand that the purpose of a USCIS Application Support Center (ASC) appointment is for me to provide my fingerprints, photograph, and/or signature and to reverify 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: By signing here, I declare under penalty of perjury that I have reviewed and understand this application as identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with this application 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.  I also understand that when I sign my name, provide my fingerprints, and am photographed at the USCIS ASC, I will be reverifying that I willingly submit this application; I have reviewed the contents of this application; all of the information in this application and all supporting documents submitted with my application 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 (if applicable) with me. Applicant’s Certification I certify, under penalty of perjury under the laws of the United States of America, that the information in this application and any document submitted with this application is complete, true, and correct. 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 my records that USCIS may need to determine my suitability and eligibility as an adoptive parent. 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 of U.S. immigration laws. Applicant’s Signature 3.Applicant's Signature Date of Signature (mm/dd/yyyy)  Applicant’s Contact Information 4. Applicant's Daytime Telephone Number 5. Applicant's Mobile Telephone Number (if any) 6. Applicant's Email Address (if any) Part 6. Applicant’s Duty of Disclosure Certification: I understand the ongoing duty to disclose information concerning my suitability and eligibility as an adoptive parent, as described in the Form I-600A and/or Form I-600 instructions, and I agree to notify the home study preparer and USCIS of any new information that I am required to disclose. Applicant’s Signature Date of Signature (mm/dd/yyyy) Part 7. Spouse’s Statement, ASC Acknowledgement (if applicable), Certification, Signature, and Contact Information Spouse’s Statement Select the box for either Item Number 1.A. or 1.B. If applicable, select the box for Item Number 2. 1.A. [Check Box] I can read and understand English, and have read and understand each and every question and instruction on this application, as well as my answer to each question. I have read and understand the Acknowledgement of Appointment at USCIS Application Support Center (if applicable). 1.B.  [Check Box] The interpreter named in Part 9. has read to me each and every question and instruction on this application, as well as my answer to each question, in [Fillable Field], a language in which I am fluent. I understand each and every question and instruction on this application as translated to me by my interpreter, and have provided complete, true, and correct responses. The interpreter named in Part 9. also has read the Acknowledgement of Appointment at USCIS Application Support Center (if applicable) to me, in the language in which I am fluent, and I understand this ASC Acknowledgement as read to me by my interpreter. 2. [Check Box] I have requested the services of and consented to [Fillable Field], who is__ is not__ an attorney or accredited representative, preparing this application for me. This person who assisted me in preparing this application has reviewed the Acknowledgement of Appointment at USCIS Application Support Center (if applicable) with me and I understand the ASC Acknowledgement. Acknowledgement of Appointment at USCIS Application Support Center (if applicable) I, [Auto-populate Field Applicant’s Spouse’s Full Name], understand that the purpose of a USCIS Application Support Center (ASC) appointment is for me to provide my fingerprints, photograph, and/or signature and to reverify that all of the information in this application is complete, true, and correct and was provided by me or my spouse. 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: By signing here, I declare under penalty of perjury that I have reviewed and understand this application as identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with this application 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.  I also understand that when I sign my name, provide my fingerprints, and am photographed at the USCIS ASC, I will be reverifying that I willingly submit this application; I have reviewed the contents of this application; all of the information in this application and all supporting documents submitted with my application 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 (if applicable) with me. Spouse’s Certification I certify, under penalty of perjury under the laws of the United States of America, that the information in this application and any document submitted with this application is complete, true, and correct. 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 my records that USCIS may need to determine my suitability and eligibility as an adoptive parent. 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 of U.S. immigration laws. Spouse’s Signature 3. Spouse's Signature Date of Signature (mm/dd/yyyy)  Spouse’s Contact Information 4. Spouse’s Daytime Telephone Number 5. Spouse’s Mobile Telephone Number (if any) 6. Spouse’s Email Address (if any) Part 8. Spouse’s Duty of Disclosure Certification: I understand the ongoing duty to disclose information concerning my suitability and eligibility as an adoptive parent, as described in the Form I-600A and/or Form I-600 instructions, and I agree to notify the home study preparer and USCIS of any new information that I am required to disclose. Spouse’s Signature Date of Signature (mm/dd/yyyy) Part 9. Interpreter’s Name, Contact Information, Certification, and Signature If you and/or your spouse (if married) used an interpreter to read and complete this application, the interpreter must provide the following information: Interpreter’s Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) 3. Interpreter’s Mailing Address Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Interpreter’s Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification I certify that: I am fluent in English and [Fillable Field]. I have read and accurately translated to this applicant and/or the applicant’s spouse (if married) every question and instruction on this application, as well as the answer to each question, in the language in which he and/or she is fluent. I have read and accurately translated the Acknowledgement of Appointment at USCIS Application Support Center (ASC) (if applicable) to the applicant and/or the applicant’s spouse, in the language in which he and/or she is fluent. The applicant and/or the applicant’s spouse has informed me that he and/or she understands every instruction and question on the application, as well as the answer to each question. The applicant and/or the applicant’s spouse also has informed me that he and/or she understands the ASC Acknowledgement and that by appearing for a USCIS ASC biometric services appointment and providing his and/or her fingerprints, photograph, and/or signature, he and/or she will be reaffirming that the contents of this application and all supporting documentation are complete, true, and correct. Interpreter’s Signature 6.   Interpreter's Signature Date of Signature (mm/dd/yyyy)  Part 10. Name, Contact Information, Statement, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant and/or Spouse If you and/or your spouse (if married) used a preparer to complete this application, the preparer must provide the following information: Preparer’s Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) 3. Preparer’s Mailing Address Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Preparer’s Contact Information 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number (if any) 6. Preparer’s Email Address (if any) Preparer’s Statement 7.A. [Check Box] I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and/or the applicant’s spouse (if married) and with the applicant’s and/or the applicant’s spouse’s consent. 7.B. [Check Box] I am an attorney or accredited representative and my representation of the applicant and/or the applicant’s spouse (if married) in this case (choose one) extends/does not extend beyond the preparation of this application. 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 and/or the applicant’s spouse (if married). I completed this application based only on responses the applicant and/or the applicant’s spouse provided to me. After completing the application, I reviewed it and all of the applicant’s and/or the applicant’s spouse’s responses with the applicant and/or the applicant’s spouse, who agreed with each and every answer on the application. If the applicant and/or applicant’s spouse supplied additional information concerning a question on the application, I recorded it on the application. I also have read the Acknowledgement of Appointment at USCIS Application Support Center (ASC) (if applicable) to the applicant and/or the applicant’s spouse and the applicant and/or the applicant’s spouse has informed me that he and/or she understands the ASC Acknowledgement. Preparer’s Signature 9. Preparer's Signature Date of Signature (mm/dd/yyyy)

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