Form I-829 Table of Changes

I829-FRM-TOC-30Day-12122014.docx

Petition by Entrepreneur to Remove Conditions

Form I-829 Table of Changes

OMB: 1615-0045

Document [docx]
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TABLE OF CHANGES – FORM

Form I-829, Petition by alien Entrepreneur to Remove Conditions

on Permanent Resident Status

OMB Number: 1615-0026

Submission Date 12/12/2014


Reason for Revision: Operational, USCIS standard formatting, and plain language updates



Current Section and Page Number

Current Text

Proposed Text

For USCIS Use Only

Received

Resubmitted

Relocated

Received

Sent


Applicant Interviewed

Received (mm/dd/yyyy)

Resubmitted (mm/dd/yyyy)

Relocated (mm/dd/yyyy)

Received (mm/dd/yyyy)

Sent (mm/dd/yyyy)


Petitioner Interviewed (mm/dd/yyyy)

To be completed by attorney or accredited representative (if any)







Fill in box if G-28 is attached to represent the applicant.


Attorney State License Number:


[Page 1]


To be completed by an attorney or accredited representative (if any).


Select this box if Form G-28 is attached to represent the petitioner.


Attorney State Bar Number (if applicable)


Attorney or Accredited Representative USCIS ELIS Account Number (if any)


New


[Page 1]


Part 1. Information About Regional Center


1. Was the investment by the entrepreneur associated with an approved regional center?


If you answered “Yes” to Item Number 1., please complete Item Numbers 2.a. - 2.c.


2.a. Name of Regional Center


2.b. Regional Center Identification Number


2.c. Receipt number for the approved Form I-924, Application For Regional Center Under the Immigrant Investor Program, upon which the related Form I-526, Immigrant Petition by Alien Entrepreneur, was based


Page 1, Part 2. Basis for Petition (Check one)







  1. My conditional permanent residence is based on an investment in a commercial enterprise.


  1. Reserved.


  1. Reserved.


  1. I am a conditional permanent resident spouse or child of an entrepreneur, and I am unable to be included in a Petition by Entrepreneur to Remove Conditions (Form I-829) filed by my conditional resident spouse or parent.


  1. I am a conditional permanent resident spouse or child of an entrepreneur who is deceased.


[Page 1]


Part 2. Basis for Petition


Select only one box.


1. I am a conditional permanent resident based on my investment in a commercial enterprise.


[Deleted]


[Deleted]


2. I am a conditional permanent resident who is the spouse, former spouse, or child of an entrepreneur, and I am filing separately from the entrepreneur's Form I-829.



3. I am a conditional permanent resident spouse or child of an entrepreneur who has died.

Page 1, Part 1. Information About You





Family Name

Given Name

Middle Name



[At beginning and end of this part]

A-Number (if any)


U.S. Social Security No (if any)]

Form I-526 Receipt Number
















Address:

In Care Of

Street Number and Name

Apt. No

City

State or Province

Country

Zip/Postal Code





















Daytime Phone No



Date of Birth


Country of Birth




Since Becoming a conditional permanent resident, have you ever been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any law or ordinance (excluding traffic regulations), or committed any crime for which you were not arrested?






(If yes, explain on a separate sheet(s) of paper, including disposition, if any.)

[Page 1]


Part 3. Information About You


1.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name



2. Alien Registration Number (A-Number) (if any)

3. USCIS ELIS Account Number (if any)

4. U.S. Social Security Number (if any)

5. Form I-526 Receipt Number on which this petition is based


Other Names You Have Used (including maiden name, nicknames, and aliases, if any)


6.a. Family Name (Last Name)

6.b. Given Name (First Name)

6.c. Middle Name


7.a. Family Name (Last Name)

7.b. Given Name (First Name)

7.c. Middle Name



[Page 2]


Your U.S. Mailing Address

8.a. In Care Of Name (if any)

8.b. Street Number and Name

8.c. Apt. Ste. Flr. [Number]

8.d. City or Town

8.e. State

8.f. ZIP Code



9. Is your mailing address the same as your physical address?


If your mailing address and the address where you currently live (physical address) are not the same, you MUST provide your current physical address in the Item Numbers 10.a. - 10.h.


Your Physical Address

10.a. Street Number and Name

10.b. Apt. Ste. Flr. [Number]

10.c. City or Town

10.d. State

10.e. ZIP Code

10.f. Postal Code

10.g. Province

10.h. Country


[Moved to Part 8.]


Other Information About You

11. Date of Birth (mm/dd/yyyy)

12. Gender Male/Female

13. Country of Birth

14. Country of Citizenship or Nationality


Criminal History

15. Since becoming a conditional permanent resident, have you EVER been arrested, cited, charged, indicted, convicted, fined, or imprisoned for violating any law or ordinance (excluding minor traffic violations)?



16. Since becoming a conditional permanent resident, have you EVER committed any crime for which you were not arrested?


If you answered “Yes” to Item Number 15., you must provide certified court dispositions, arrest reports, statements of charges, indictment information, or any other charging documents that were issued. If you answered “Yes” to Item Number 16., provide the date and location (town or city/state or province/country) of the events and provide an explanation in Part 11. Additional Information

.

Page 1, Part 3. Information About Your Husband or Wife







Family Name

Given Name

Middle Name


Gender Male/Female

A-Number (if any)


Date of Birth (mm/dd/yyyy)


Other names used (including maiden name or aliases


























Date of Marriage (mm/dd/yyyy)




Current Immigration Status



Is your current status based on the petitioner’s current status



[Page 2]


Part 4. Information About Your Current Spouse or Your Former Conditional Permanent Resident Spouse


1.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name


2. Gender Male/Female

3. A-Number (if any)

4. USCIS ELIS Account Number (if any)

5. Date of Birth (mm/dd/yyyy)


Other Names Used (if applicable)

6.a. Family Name (Last Name)

6.b. Given Name (First Name)

6.c. Middle Name


7.a. Family Name (Last Name)

7.b. Given Name (First Name)

7.c. Middle Name




[Page 3]


Mailing Address

8.a. Street Number
and Name

8.b. Apt. Ste. Flr.

8.c. City or Town

8.d. State

8.e. ZIP Code

8.f. Postal Code

8.g. Province

8.h. Country


Other Information

9. Current Spouse/Former Conditional Permanent Resident Spouse

10. Date of Marriage (mm/dd/yyyy)

11. Date Marriage Terminated (mm/dd/yyyy)

12. Is this spouse currently living with you?

13. Is this spouse applying with you?

14. Current Immigration Status (for example, conditional resident, tourist/visitor, entered without inspection)

15. Is the current immigration status of your spouse or former spouse based on your current immigration status?



NOTE: If you have both a current spouse and a former conditional permanent resident spouse, use Part 11. Additional Information to provide this same information about your current spouse or former conditional permanent resident spouse who you did not already include in Part 4. above.

Page 2, Part 4. Children (List all of your children. Attach another sheet(s) or paper, if necessary.)










Family Name

Given Name

Middle Name


A-Number (if any)


Date of Birth (mm/dd/yyyy)






















Living with you?


Current Immigration Status






Family Name

Given Name

Middle Name



A-Number (if any)


Date of Birth (mm/dd/yyyy)

















Living with you?


Current Immigration Status





Family Name

Given Name

Middle Name



A-Number (if any)







Date of Birth (mm/dd/yyyy)

















Living with you?


Current Immigration Status






Family Name

Given Name

Middle Name



A-Number (if any)


Date of Birth (mm/dd/yyyy)

















Living with you?


Current Immigration Status












[Page 3]


Part 5. Information About Your Children


Provide the following information about your children.


Child 1

1.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name


2. Gender Male/Female

3. A-Number (if any)

4. USCIS ELIS Account Number (if any)

5. Date of Birth (mm/dd/yyyy)


Other Names Used (if applicable)

6.a. Family Name (Last Name)

6.b. Given Name (First Name)

6.c. Middle Name


Mailing Address


7.a. Street Number and Name

7.b. Apt. Ste. Flr.

7.c. City or Town

7.d. State

7.e. ZIP Code

7.f. Province

7.g. Postal Code

7.h. Country



[Page 4]


Child 1 (continued)

8. Is this child currently living with you?

9. Is this child applying with you?

10. Current Immigration Status (for example, conditional resident, tourist/visitor, entered without inspection)



Child 2

11.a. Family Name (Last Name)

11.b. Given Name (First Name)

11.c. Middle Name


12. Gender Male/Female

13. A-Number (if any)

14. USCIS ELIS Account Number (if any)

15. Date of Birth (mm/dd/yyyy)


Other Names Used (if applicable)

16.a. Family Name (Last Name)

16.b. Given Name (First Name)

16.c. Middle Name


Mailing Address

17.a. Street Number and Name

17.b. Apt. Ste. Flr.

17.c. City or Town

17.d. State

17.e. ZIP Code

17.f. Province

17.g. Postal Code

17.h. Country


18. Is this child currently living with you?

19. Is this child applying with you?

20. Current Immigration Status (for example, conditional resident, tourist/visitor, entered without inspection)


Child 3

21.a. Family Name (Last Name)

21.b. Given Name (First Name)

21.c. Middle Name


22. Gender Male/Female

23. A-Number (if any)



[Page 5]


Child 3 (continued)

24. USCIS ELIS Account Number (if any)

25. Date of Birth (mm/dd/yyyy)


Other Names Used (if applicable)

26.a. Family Name (Last Name)

26.b. Given Name (First Name)

26.c. Middle Name


Mailing Address

27.a. Street Number and Name

27.b. Apt. Ste. Flr.

27.c. City or Town

27.d. State

27.e. ZIP Code

27.f. Province

27.g. Postal

27.h. Country


28. Is this child currently living with you?

29. Is this child applying with you?

30. Current Immigration Status (for example, conditional resident, tourist/visitor, entered without inspection)



Child 4

31.a. Family Name (Last Name)

31.b. Given Name (First Name)

31.c. Middle Name


32. Gender Male/Female

33. A-Number (if any)

34. USCIS ELIS Account Number (if any)

35. Date of Birth (mm/dd/yyyy)


Other Names Used (if applicable)

36.a. Family Name (Last Name)

36.b. Given Name (First Name)

36.c. Middle Name


Mailing Address

37.a. Street Number and Name

37.b. Apt. Ste. Flr.

37.c. City or Town

37d. State

37.e. ZIP Code

37.f. Province

37.g. Postal Code

37.h. Country


38. Is this child currently living with you?

39. Is this child applying with you?

40. Current Immigration Status (for example, conditional resident, tourist/visitor, entered without inspection)


If you need extra space to list additional children, use the space provided in Part 11. Additional Information 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.

New


[Page 6]


Part 6. Your Biographic Information


1. Ethnicity (Select only one box)

Hispanic or Latino

Not Hispanic or Latino


2. Race (Select all applicable boxes)

White

Asian

Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander


3. Height Feet Inches


4. Weight Pounds


5. Eye Color (Select only one box)

Black

Blue

Brown

Gray

Green

Hazel

Maroon

Pink

Unknown/Other


6. Hair Color (Select only one box)

Bald (No hair)

Black

Blond

Brown

Gray

Red

Sandy

White

Unknown/Other

Page 2 - 3, Part 5. Information About Your Commercial Enterprise

[Page 2]





Type of Enterprise (Check one):


New commercial enterprise resulting from the creation of a new business.


New commercial enterprise resulting from the reorganization of an existing business.



New commercial enterprise resulting from a capital investment in an existing business.




Kind of Business (Be as specific as possible):

























Date Business Established (mm/dd/yyyy)

Amount of Initial Investment


Date of Initial Investment (mm/dd/yyyy)


% of Enterprise You Own




[Page 3]


Subsequent Investment in the Enterprise:





Date of Investment


Amount of Investment

Type of Investment






Date of Investment

Amount of Investment

Type of Investment


Date of Investment

Amount of Investment

Type of Investment









Number of full-time employees in enterprise in United States (excluding you, your spouse, sons, and daughters):




At time of your initial investment:



Presently:

Difference:




How many of these new jobs were created by your investment?






















Provide the gross and net incomes generated annually by the commercial enterprises since your initial investment. Include all income generated up to date the present year.


Year

Gross Income

Net Income


Year

Gross Income

Net Income


Year

Gross Income

Net Income


Has your commercial enterprise filed for bankruptcy, ceased business operations, or have any changes in its business organization or ownership occurred since the date of your initial investment?

Yes (Explain on separate sheet) No


Has your commercial enterprise sold any corporate assets, shares, property, or had any capital withdrawn since the date of your initial investment?

Yes (Explain on separate sheet) No


[Page 6]


Part 7. Information About the New Commercial Enterprise (NCE)


Type of Enterprise


1. NCE formed after November 29, 1990.



2. NCE resulting from the purchase of a business, formed on or before November 29, 1990, that has been restructured or reorganized.

3. NCE resulting from a capital investment in, and substantial expansion of, a business formed on or before November 29, 1990.



Additional Information About the NCE

4. Name of the NCE


Physical Address

5.a. Street Number and Name

5.b. Apt. Ste. Flr.

5.c. City or Town

5.d. State

5.e. ZIP Code


6. Telephone Number

7. Internet Web site Address (if established)

8. Type of Business Organization (for example, corporation, limited liability company, partnership)

9. Nature of Business (for example, furniture manufacturer)

10. Included Industries (select North American Industry Classification System (NAICS) code or codes)

11. IRS Tax Identification Number



[Page 7]


12. Date Business Established (mm/dd/yyyy)

13. Amount of the Entrepreneur's Initial Investment in the NCE

14. Date of the Entrepreneur's Initial Investment (mm/dd/yyyy)

15. What percentage of the NCE does the entrepreneur own?

16. Is this petition based on investment in a troubled business?



Subsequent Investments in the NCE

Provide the following information about how much the entrepreneur has invested in the NCE since the entrepreneur's initial investment.


17.a. Date of Subsequent Investment (mm/dd/yyyy)

17.b. Amount of Subsequent Investment

17.c. Type of Subsequent Investment (for example, cash, equipment, inventory, other tangible property, cash equivalents, or qualifying indebtedness as described in

8 CFR 204.6(e))


[Delete]

[Delete]

[Delete]


[Delete]

[Delete]

[Delete]



NOTE: If multiple investments have been made since the entrepreneur's initial investment in the commercial enterprise, use Part 11. Additional Information to list the dates, amounts, and types of investments.


Full-time Positions and Qualifying Employees Provide the number of full-time positions for direct and qualifying employees in the NCE in the United States (excluding you, your spouse, and your children):


18.a. At the time of the Entrepreneur's Initial Investment


[Delete]

[Delete]


18.b. Currently Employed in the NCE


Job Creation

19.a. How many new direct jobs did the entrepreneur's investment create?

19.b. How many new direct jobs will the entrepreneur's investment create within a reasonable amount of time after filing this petition?

20.a. If the NCE is associated with an approved regional center, how many indirect jobs were created?

20.b. If the NCE is associated with an approved regional center, how many indirect jobs will the NCE create within a reasonable amount of time after filing this petition?


[new]


21. If the investment was made into a troubled business, how many jobs were maintained as a result of the investment?



Gross and Net Incomes

Provide the gross and net incomes generated annually by the commercial enterprise since the entrepreneur's initial investment. Include all income generated in the present year to date.


22.a. Year (yyyy)

22.b. Gross Income

22.c. Net Income


23.a. Year (yyyy)

23.b. Gross Income

23.c. Net Income


24.a. Year (yyyy)

24.b. Gross Income

24.c. Net Income


25. Has the commercial enterprise filed for bankruptcy, ceased business operations, materially changed the nature of the business, or made any changes in its organization or ownership since the date of the entrepreneur's initial investment? Yes/No


26. Has the commercial enterprise sold any corporate assets, shares, or property, or had any capital withdrawn since the date of the entrepreneur's initial investment? Yes/No



NOTE: If you answered “Yes” to Item Number 25. or 26., provide an explanation in Part 11. Additional Information.


[new]


27. Provide the total number of EB-5 investors associated with the NCE.


28. Provide the total amount of EB-5 capital invested into the NCE.


If you need extra space to provide additional information for any item in Part 7., use the space provided in Part 11. Additional Information 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.

Page 3, Part 6. Signature (Read the information on penalties in the instructions before completing this section)















































































































I certify, under penalty of perjury under the laws of the United States of America, that this petition and the evidence submitted with it is all true and correct. I further certify that the investment was made in accordance with the laws of the United States and was not for the purpose of evading United Stated immigration laws. I also authorize the release of any information from my records that the U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit being sought.



Signature of Applicant

Print Name

Date


NOTE: If you do not completely fill out this form or fail to submit any required documents listed in the instructions, you may not be found eligible for the requested benefit and this petition may be denied.


[Page 8]


Part 8. Petitioner'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-829 Instructions before completing this part.


Petitioner’s Statement


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 petition, as well as my answer to every question. I have read the Acknowledgement of Appointment at USCIS Application Support Center.


1.b. The interpreter named in Part 9. has read every question and instruction on this petition, as well as my answer to every question, in , a language in which I am fluent. I understand every question and instruction on this petition 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 9. 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.


2. I have requested the services of and consented to , who is is not an attorney or accredited representative, in preparing this petition for me. This person who assisted me in preparing my petition has reviewed the Acknowledgement of Appointment at USCIS Application Support Center with me and I understand the ASC Acknowledgement.


Petitioner's Contact Information

3. Petitioner's Daytime Telephone Number

4. Petitioner's Mobile Phone Number (if any)

5. Petitioner's Email Address (if any)


Acknowledgement of Appointment at USCIS Application Support Center


I, _____________________________________, understand that the purpose of a USCIS ASC appointment is for me to provide fingerprints, photograph, and/or signature and to re-affrim that all of the information in my petition 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, photographs, and/or signature during my USCIS ASC appointment:


By signing here, I declare under penalty of perjury that I have reviewed and understand my petition, as identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with my petition 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 re-affirming that I willingly submit this petition; I have reviewed the contents of this petition; all of the information in my petition and all supporting documents submitted with my petition were provided by me and are complete, true, and correct; and if I was assisted in completing this petition, the person assisting me also reviewed this Acknowledgement of Appointment at USCIS Application Support Center with me.


Petitioner'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 furthermore authorize release of information contained in this petition, 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.


I certify, under penalty of perjury, that the information in my petition and any document submitted with my petition were provided by me and are complete, true and correct.









Petitioner's Signature

6.a. Petitioner's Signature

[Delete]

6.b. Date of Signature (mm/dd/yyyy)


NOTE TO ALL PETITIONERS: If you do not completely fill out this petition or fail to submit required documents listed in the instructions, your petition may be denied.

NEW


[Page 9]


Part 9. Interpreter's Certification, Contact Information, 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)

2. Interpreter's Business or Organization Name (if any)


Interpreter's Mailing Address

3.a. Street Number and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State

3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. 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 _____________,

which is the same language provided in Part 8., Item Number 1.b.;


I have read to this petitioner every question and instruction on this petition, as well as the answer to every question, in the language provided in Part 8., Item Number 1.b.; and


I have read the Acknowledgement of Appointment at USCIS Application Support Center to the petitioner in the same language provided in Part 8., Item Number 1.b.


The petitioner has informed me that he or she understands every instruction and question on the petition, as well as the answer to every question, and the petitioner verified the accuracy of every answer; and


The petitioner 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 petition and all supporting documentation are complete, true, and correct.



Interpreter's Signature

6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy)

Page 3, Part 7. Signature of Person Preparing Form, If Other Than Above












Print Name









Firm Name and Address (Include Telephone Number with Area Code and E-Mail Address.)






























I declare that I prepared this petition at the request of the above person and it is based on all information of which I have knowledge.















Signature

Printed Name

Date

[Page 9]


Part 10. Contact Information, Statement, Certification, and Signature of the Person Preparing this Petition, If Other Than the Petitioner


Provide the following information about the preparer.


Preparer's Full Name

1.a. Preparer's Family Name (Last Name)

1.b. Preparer's Given Name (First Name)

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


Preparer's Mailing Address

3.a. Street Number and Name

3.b. Apt. Ste. Flr.

3.c. City or Town

3.d. State

3.e. ZIP Code

3.f. Province

3.g. Postal Code

3.h. Country


[Page 10]


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. I am not an attorney or accredited representative but have prepared this petition on behalf of the petitioner and with the petitioner's consent.

7.b. I am an attorney or accredited representative and my representation of the petitioner in this case extends does not extend beyond the preparation of this petition.


NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this petition, you must submit a completed Form G-28, Notice of Attorney or Accredited Representative, with this petition.


Preparer's Certification

By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this petition on behalf of, at the request of, and with the express consent of the petitioner. I completed this petition based only on responses the petitioner provided to me. After completing the petition, I reviewed it and all of the petitioner's responses with the petitioner, who agreed with every answer on the petition. If the petitioner supplied additional information concerning a question on the petition, I recorded it on the petition. I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the petitioner and the petitioner has informed me that he or she understands the ASC Acknowledgement.


Preparer's Signature

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)



NEW


[Page 11]


Part 11. Additional Information If you need extra space to provide any additional information within this petition, 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 petition or attach a separate sheet of paper. Include 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.


1.a. Family Name (Last Name)

1.b. Given Name (First Name)

1.c. Middle Name


2. A-Number (if any)


3.a. Page Number

3.b. Part Number

3.c. Item Number

3.d.


4.a. Page Number

4.b. Part Number

4.c. Item Number

4.d.


5.a. Page Number

5.b. Part Number

5.c. Item Number

5.d.


6.a. Page Number

6.b. Part Number

6.c. Item Number

6.d.


7.a. Petitioner's Signature

7.b. Date of Signature (mm/dd/yyyy)


2

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