Current Section and Page
Number
|
Current Text
|
Proposed
Text
|
Page 1,
To be completed by an
attorney or accredited representative (if any).
|
To be completed by an attorney or
accredited representative (if any).
Check the box if Form G-28 is
attached to represent the petitioner
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.
Attorney State Bar
Number (if applicable)
Attorney or
Accredited Representative USCIS ELIS Account Number
(if any)
|
Pages 1-2,
Part 1. Information
About You, the Conditional Resident
|
Part 1. Information About You,
the Conditional Resident
1.a. Family Name (Last
Name)
1.b. Given Name (First
Name)
1.c. Middle Name
Other Names Used
(including maiden name)
2.a. Family Name (Last
Name)
2.b. Given Name (First
Name)
2.c. Middle Name
3.a. Family Name (Last
Name)
3.b. Given Name (First
Name)
3.c. Middle Name
Other Information
4. Date of Birth
(mm/dd/yyyy)
5. Country of Birth
6. Country of Citizenship
7. Alien Registration Number
(A-Number)
8. U.S. Social Security
Number (if any)
Contact Information
9. Daytime Phone Number
10. E-Mail Address (if
any)
Marital Status
11. Marital Status
Married/Single/Divorced/Widowed
12. Date of Marriage
(mm/dd/yyyy)
13. Place of Marriage
14. If the marriage through
which you gained conditional residence has ended, give the date it
ended (date of
divorce or date of death) (mm/dd/yyyy)
15. Conditional Residence
Expires On (mm/dd/yyyy)
[Page 2]
Mailing Address (If
different than Physical Address)
17.a. In
Care
Of
Name
17.b. Street
Number and
Name
17.c. Apt. Ste. Flr. [ ]
17.d. City or Town
17.e. State
17.f. Zip Code
Physical Address
16.a. In
Care
Of
Name
16.b. Street
Number and
Name
16.c. Apt. Ste. Flr. [ ]
16.d. City or Town
16.e. State
16.f. Zip Code
Additional Information About
You
18. Are you
in removal, deportation, or rescission proceedings?
19. Was a fee paid to anyone
other than an attorney in connection with this petition?
20. Have you ever been
arrested, detained, charged, indicted, fined, or imprisoned
for breaking or violating any law or ordinance (excluding traffic
regulations), or committed any crime which you were not arrested
in the United States or abroad?
21. If you are married, is
this a different marriage than the one through which conditional
residence status was obtained?
22. Have you resided at any
other address since you became a permanent resident? (If
“Yes,” attach a list of all addresses and dates.)
23. Is your spouse or
parent’s spouse currently serving with or employed by the
U.S. Government and serving outside the United States?
If you answered "Yes" to
Item Number 20., provide a detailed explanation on a
separate sheet of paper and refer to the section entitled "What
Initial Evidence Is Required?" to determine what criminal
history document to include with your petition.
|
[Page 1]
START HERE - Type or print in
black ink.
Part 1.
Information About You, the Conditional Resident
[No change]
Other
Names Used
List all other
names you have ever used, including aliases, maiden name, and
nicknames. If you need extra space to complete this section, use
the space provided in Part 11.
Additional Information.
2.a.Family
Name (Last Name)
2.b.Given Name
(First Name)
2.c.Middle
Name
3.a.Family
Name (Last Name)
3.b.Given Name
(First Name)
3.c.Middle
Name
[No change]
6. Country of Citizenship or
Nationality (provide all that apply)
7. Alien Registration Number
(A-Number) (if any)
8. U.S. Social Security
Number (if any)
9.
USCIS ELIS Account Number (if any)
[Deleted]
Marital Status
10.
Marital Status
Single/Married/Divorced/Widowed
11. Date of Marriage
(mm/dd/yyyy)
12. [No change]
13.
If the marriage through which you gained conditional
residence has ended, provide the date
it ended (date of
divorce or date of death) (mm/dd/yyyy)
14.
Conditional Residence Expires On (mm/dd/yyyy)
[Page 2]
Mailing Address
15.a.
In Care Of Name
15.b.
Street
Number
and
Name
15.c.
Apt. Ste. Flr.
15.d.
City or Town
15.e.
State
15.f.
ZIP Code
16. Is your
physical address different than your mailing address? Yes/No
If you
answered “Yes” to Item
Number 16., provide your physical
address below.
Physical Address
17.a.
In
Care
Of
Name
17.b.
Street
Number and
Name
17.c.
Apt. Ste. Flr.
17.d.
City or Town
17.e.
State
17.f.
ZIP Code
Additional Information About
You
18.
Are you in removal, deportation, or rescission
proceedings?
19.
Was a fee paid to anyone other than an attorney in
connection with this petition?
20.
Have you ever been arrested, detained, charged,
indicted, fined, or imprisoned for breaking or violating any
law or ordinance (excluding traffic regulations), or committed any
crime which you were not arrested in the United States or abroad?
If you answered "Yes" to
Item Number 20.,
provide a detailed explanation in Part
11. Additional Information or on a separate sheet of
paper, and refer to the What
Initial Evidence Is Required
section of the Form I-751
instructions to determine what
criminal history document to include with your petition.
21.
If you are married, is this a different marriage than the
one through which you gained conditional
resident status?
Yes/No
22.
Have you resided at any other address since you became a
permanent resident? Yes/No
If you
answered “Yes” to Item
Number 22., provide
a list of all addresses where you
have resided since becoming a permanent resident and the
dates you resided at those locations in the
space provided in Part 11.
Additional Information.
23.
Is your spouse or parent’s spouse currently serving
with or employed by the U.S. Government and serving outside
the United States? Yes/No
[moved this paragraph to come after
Item Number 20]
|
New
|
|
[Page 2]
Part 2.
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,
Part 2. Basis for
Petition
|
Part 2. Basis for Petition
Joint Filing
My conditional residence is based on
my marriage or my parent's marriage to a U.S. citizen or permanent
resident, and I am filing this joint petition together with:
1.a. My spouse
1.b. My parent's spouse
because I am unable to be included in a joint petition filed by my
parent and my parent's spouse.
OR (check all that apply)
Waiver Request Filing
My conditional residence is based on
my marriage or my parent's marriage to a U.S. citizen or permanent
resident; I am unable to file a joint petition with my spouse or
my parent's spouse and I request a hardship waiver because:
1.c. My spouse or my
parent's spouse is deceased.
1.d. I or my parent entered
the marriage in good faith, but the marriage was terminated
through divorce or annulment.
1.e. I entered the marriage
in good faith, and, during the marriage, I was battered, or was
the subject of extreme cruelty, by my U.S. citizen or permanent
resident spouse.
1.f. My parent entered the
marriage in good faith and, during the marriage, I was battered,
or was subjected to extreme cruelty, by my parent's U.S. citizen
or permanent resident spouse or by my conditional resident parent.
1.g. The termination of my
status and removal from the United States would result in an
extreme hardship.
|
[Page 2]
Part 3.
Basis for Petition
Joint Filing
My conditional residence is based on
my marriage or my parent's marriage to a U.S. citizen or lawful
permanent resident, and I am filing this joint petition
together with (Select
only
one
box):
1.a. My spouse.
1.b. [No change]
OR (Select
all applicable
boxes in the next section.)
[Page 3]
Waiver or Individual Filing
Request
My conditional residence is based on
my marriage or my parent's marriage
to a U.S. citizen or lawful permanent
resident, I am unable to file a joint
petition with my spouse or my parent's spouse,
because:
1.c.
My spouse is deceased.
1.d.
My marriage was entered in good faith, but the marriage was
terminated through divorce or annulment.
1.e. I entered the marriage
in good faith, and, during the marriage, I was battered, or was
the subject of extreme cruelty, by my U.S. citizen or lawful
permanent resident spouse.
1.f. My parent entered the
marriage in good faith, and, during
the marriage, I was battered, or was subjected to extreme cruelty,
by my parent’s U.S. citizen or lawful
permanent resident spouse or by my conditional resident
parent.
[No change]
|
Page 3,
Part 3. Information
About the Petitioning Spouse or, If Filing as a Child Separately,
Information About the U.S. Citizen or LPR Stepparent Through Whom
You Gained Your Conditional Residence
|
Part 3.
Information About the Petitioning Spouse or, If Filing as a Child
Separately, Information About the U.S. Citizen or LPR Stepparent
Through Whom You Gained Your Conditional Residence
Relationship
1.a. Spouse or Former Spouse
1.b. Parent’s Spouse
or Former Spouse
2.a. Family Name (Last
Name)
2.b. Given Name (First
Name)
2.c. Middle Name
3. Date of Birth
(mm/dd/yyyy)
4. U.S. Social Security
Number (if any)
5. Alien Registration Number
(A-Number)
6.a. Street
Number and
Name
6.b. Apt. Ste. Flr. [ ]
6.c. City or Town
6.d. State
6.e. Zip Code
6.f. Postal Code
6.g. Province
6.h. Country
|
[Page 3]
Part 4.
Information About the U.S.
Citizen or Lawful Permanent Resident Spouse. If
Filing as a Child Separately, Information About the U.S. Citizen
or Lawful Permanent Resident
Stepparent Through Whom You Gained Your Conditional
Residence.
[No change- italics removed]
Other
Information
[No change- italics removed]
5. A-Number (if
any)
Physical
Address
6.a. Street
Number and
Name
6.b. Apt.
Ste. Flr.
6.c. City or Town
6.d. State
6.e. ZIP
Code
6.f. Province
6.g. Postal
Code
6.h. Country
|
Pages 3-4,
Part 4. Information
About Your Children
|
Part 4. Information About Your
Children
List All Your Children (Attach other
sheets if necessary).
Child 1
1.a. Family Name (Last Name)
1.b. Given Name (First Name)
1.c. Middle Name
2. Date of Birth
(mm/dd/yyyy)
3. Alien Registration Number
(A-Number)
5. Is child living with you?
6. Is child applying with
you?
4.a. Street
Number and
Name
4.b. Apt. Ste. Flr. [ ]
4.c. City or Town
4.d. State or Province
4.e. Zip Code or Postal Code
4.f. Country
Child 2
7.a. Family Name (Last Name)
7.b. Given Name (First Name)
7.c. Middle Name
7. Date of Birth
(mm/dd/yyyy)
9. Alien Registration Number
(A-Number)
11. Is child living with
you?
12. Is child applying with
you?
10.a. Street
Number and
Name
10.b. Apt. Ste. Flr. [ ]
10.c. City or Town
10.d. State or Province
10.e. Zip Code or Postal
Code
10.f. Country
Child 3
13.a. Family Name (Last
Name)
13.b. Given Name (First
Name)
13.c. Middle Name
14. Date of Birth
(mm/dd/yyyy)
15. Alien Registration Number
(A-Number)
17. Is child living with
you?
18. Is child applying with
you?
[Page 4]
16.a. Street
Number and
Name
16.b. Apt. Ste. Flr. [ ]
16.c. City or Town
16.d. State or Province
16.e. Zip Code or Postal
Code
16.f. Country
Child 4
19.a. Family Name (Last
Name)
19.b. Given Name (First
Name)
19.c. Middle Name
20. Date of Birth
(mm/dd/yyyy)
21. Alien Registration Number
(A-Number)
23. Is child living with
you?
23. Is child applying with
you?
22.a. Street
Number and
Name
22.b. Apt. Ste. Flr. [ ]
22.c. City or Town
22.d. State or Province
22.e. Zip Code or Postal
Code
22.f. Country
Child 5
25.a. Family Name (Last
Name)
25.b. Given Name (First
Name)
25.c. Middle Name
26. Date of Birth
(mm/dd/yyyy)
27. Alien Registration Number
(A-Number)
29. Is child living with
you?
30. Is child applying with
you?
28.a. Street
Number and
Name
28.b. Apt. Ste. Flr. [ ]
28.c. City or Town
28.d. State or Province
28.e. Zip Code or Postal
Code
28.f. Country
|
[Page 3]
Part 5.
Information About Your Children
Provide
information on all of your children. If you need extra space to
complete this section, use the space provided in Part
11. Additional Information.
Child 1
[No change- remove italics]
3. A-Number (if
any)
4. Is this
child living with you?
5. Is this
child applying with you?
Physical
Address
6.a. Street
Number and
Name
6.b. Apt. Ste. Flr. [ ]
6.c. City or Town
6.d. State
6.e. ZIP
Code
6.f. Province
6.g.
Postal Code
6.h.
Country
[Page 4]
[No change- remove italics]
8.
Date of Birth (mm/dd/yyyy)
9. A-Number (if
any)
10. Is this
child living with you?
11. Is this
child applying with you?
Physical
Address
12.a. Street
Number and
Name
12.b. Apt. Ste. Flr. [ ]
12.c. City or Town
12.d. State
12.e. ZIP
Code
12.f. Province
12.g.
Postal Code
12.h.
Country
[No change-remove italics]
15. A-Number (if
any)
16. Is this
child living with you?
17. Is this
child applying with you?
Physical
Address
18.a. Street
Number and
Name
18.b. Apt. Ste. Flr. [ ]
18.c. City or Town
18.d. State
18.e. ZIP
Code
18.f. Province
18.g.
Postal Code
18.h.
Country
[No change]
20. Date of Birth
(mm/dd/yyyy)
21. A-Number
(if any)
22. Is this
child living with you?
23. Is this
child applying with you?
Physical
Address
24.a. Street
Number and
Name
24.b. Apt. Ste. Flr. [ ]
24.c. City or Town
24.d. State
24.e. ZIP
Code
24.f. Province
24.g.
Postal Code
24.h.
Country
[Page 5]
[No change]
26. Date of Birth
(mm/dd/yyyy)
27. A-Number (if
any)
28. Is this
child living with you?
29. Is this
child applying with you?
Physical
Address
30.a. Street
Number and
Name
30.b. Apt. Ste. Flr. [ ]
30.c. City or Town
30.d. State
30.e. ZIP
Code
30.f. Province
30.g.
Postal Code
30.h.
Country
|
Pages 4-5,
Part 5.
Accommodations for Individuals With Disabilities and Impairments
(Read the
information in the instructions before completing this section.)
|
[Page 4]
Part 5. Accommodations for
Individuals With Disabilities and Impairments (Read the
information in the instructions before completing this section.)
I am requesting an accommodation:
1. Because of my
disability(ies) and/or impairment(s).
2. For my spouse because of
his or her disability(ies) and/or impairment(s).
3. For my included
child(ren) because of his or her (their) disability(ies) and/or
impairment(s).
If you answered "Yes,"
check any applicable box. Provide information on the
disability(ies) and/or impairment(s) for each person:
4.a. 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)):
4.b. Blind or sight-impaired
and request the following accommodation(s):
[Page 5]
4.c. 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 6.
Accommodations for Individuals With Disabilities
and/or Impairments
NOTE:
Read the information in the Form I-751 instructions before
completing this part.
1.
Are you requesting an accommodation because of your disabilities
and/or impairments?
2.
Are you requesting an accommodation because of your spouse’s
disabilities and/or impairments?
3.
Are you requesting an accommodation because of your included
children’s disabilities and/or impairments?
If you answered “Yes”
to Item Numbers 1. - 3.,
select any applicable box for Item
Numbers 4.a. - 4.c. Provide information on the
disabilities and/or impairments
for each person.
4.a.
I am deaf or hard of hearing and
request the following accommodation.
(If you are requesting a
sign-language interpreter, indicate for
which language (for
example, American Sign Language).):
4.b.
I am blind or have
low vision and request the following
accommodation:
4.c.
I have another type of disability
and/or impairment.
(Describe the nature of your
disability and/or impairment
and the accommodation
you are requesting.):
|
Page 5,
Part
6. Signature (Read
the information on penalties in the instructions before completing
this section. If you checked Block
1.a.
in Part 2, your spouse must also sign below. Signature of a
conditional resident child under the age of 14 is not required; a
parent may sign for the child).
|
[Page 5]
Part 6. Signature (Read
the information on penalties in the instructions before completing
this section. If you checked Block
1.a. in Part 2, your spouse must
also sign below. Signature of a conditional resident child under
the age of 14 is not required; a parent may sign for the child).
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. If
conditional residence was based on a marriage, I further certify
that the marriage was entered in accordance with the laws of the
place where the marriage took place and was not for the purpose of
procuring an immigration benefit. I also authorize the release of
any information from my records that U.S. Citizenship and
Immigration Services needs to determine eligibility for the
benefit sought.
Signature of Conditional
Resident
1.a. Signature of
Conditional Resident
1.b. Printed Name of
Conditional Resident
2. Date of Signature
(mm/dd/yyyy)
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 5]
Part 7.
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-751 Instructions before completing this
part.
NOTE:
If you selected Box 1.a.
in Part 3.,
your spouse must also read and sign the petition in Part
8. Signature of a conditional
resident child under 14 years of age is not required; a parent may
sign for a child.
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 and understand the Acknowledgement
of Appointment at USCIS Application
Support Center.
[Page 6]
1.b.
The interpreter named in Part
9. has also read to me every
question and instruction on this petition,
as well as my answer to every
question, in [Fillable Field], 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 [Fillable
Field], who is is not an attorney or
accredited representative, 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 Telephone Number
(if any)
5.
Petitioner’s Email Address (if any)
Acknowledgement
of Appointment at USCIS Application
Support Center
I,
[Auto-populate Field with Petitioner’s Full Name],
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 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,
photograph, and/or signature during my ASC appointment.
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.
If conditional
residence was based on a marriage, I further certify that the
marriage was entered into in accordance with the laws of the place
where the marriage took place and was not for the purpose of
procuring an immigration benefit.
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,
my responses to each question, 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, USCIS may deny your
petition.
NOTE:
If you are filing based on claims of having been battered or
subjected to extreme cruelty waiver or individual filing, you are
not required to have the spouse’s or individual listed in
Part 4’s
signature.
|
New
|
[Page 5, Part 6. Signature]
Signature of Spouse or
Individual Listed in Part 3 (if applicable)
3.a. Signature of Spouse
3.b. Printed Name of Spouse
4. Date of Signature
(mm/dd/yyyy)
|
[Page 7]
Part 8.
Spouse’s or Individual Listed in Part 4.’s Statement,
Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature (if
applicable)
Provide
the following information about
the spouse or individual listed in Part
4.
NOTE:
Read the information on penalties in the Penalties
section of the Form I-751 Instructions before completing this
part.
Spouse’s
or Individual’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 the petitioner’s answer to every question.
I have read and understand the Acknowledgement
of Appointment at USCIS Application
Support Center.
1.b.
The interpreter named in
Part 9.
has also read to me every question and instruction on this
petition, as
well as the petitioner’s answer
to every question, in [Fillable
Field], 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 [Fillable
Field], who is is not an attorney or
accredited representative, 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.
Spouse’s
or Individual’s
Contact Information
3.
Spouse’s or Individual’s Daytime Telephone Number
4.
Spouse’s or Individual’s Mobile Telephone (if any)
5.
Spouse’s or Individual’s Email Address (if any)
Acknowledgement
of Appointment at USCIS Application
Support Center
I,
[Auto-populate Field with Spouse’s or Individual’s
Full Name], 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 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, photograph, and/or signature during my
ASC appointment.
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.
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.
Spouse’s
or Individual’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,
my responses to each question, and
any document submitted with my petition
were provided by me and are complete, true, and correct.
Spouse’s
or Individual’s
Signature
6.a.
Spouse’s or Individual’s Signature
[delete]
6.b.
Date of Signature (mm/dd/yyyy)
NOTE TO ALL
SPOUSES OR INDIVIDUALS: If you
do not completely fill out this petition or fail to submit
required documents listed in the instructions, USCIS may deny your
petition.
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[Page 8]
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)
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 [Fillable Field], which is the same language provided
in Part 7.,
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 7.,
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
7., 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)
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Part 7. Signature and
Contact Information of Person Preparing Form, If Other Than Above
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[Page 5]
Part 7. Signature and Contact
Information of Person Preparing Form, If Other Than Above
Preparer's
Full Name
3.a.
Preparer’s Family Name (Last Name)
3.b.
Preparer’s Given Name (First Name)
4.
Preparer’s Business or Organization Name (if
any)
Preparer’s Mailing
Address
5.a. Street Number and Name
5.b. Apt. Ste. Flr.
5.c. City or Town
5.d. State
5.e. ZiP Code
Preparer’s Contact
Information
6.
Preparer’s Daytime Telephone Number
7. Preparer’s Email
Address (if any)
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.
1. Signature of Preparer
2. Date of Signature (mm/dd/yyyy)
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[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
Preparer’s
Contact Information
4.
Preparer’s Daytime
Telephone Number
5.
Preparer’s Fax Number
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 Entry of Appearance as
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)
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[Page 10]
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.
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.
1.a.
Family Name (Last Name) [Auto-populated field]
1.b.
Given Name (First Name) [Auto-populated field]
1.c.
Middle Name [Auto-populated field]
2.
A-Number (if any) [Auto-populated field]
3.a.
Page Number
3.b.
Part Number
3.c.
Item Number
3.d.
[Fillable field]
4.a.
Page Number
4.b.
Part Number
4.c.
Item Number
4.d.
[Fillable field]
5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
[Fillable field]
6.a.
Page Number
6.b.
Part Number
6.c.
Item Number
6.d.
[Fillable field]
7.a.
Page Number
7.b.
Part Number
7.c.
Item Number
7.d.
[Fillable field]
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