Page 1,
Information About You
|
Part
1.
Information
About You (Person
filing this Application)
1.
I am the (select only
one):
Applicant Petitioner on the previously approved application or
petitioner.
2.a.
Family Name
(Last Name)
2.b.
Given Name
(First name)
2.c.
Middle Name
3.
Company or
Organization Name
Provide
the following information about the petitioner or applicant for
the previous petition or application.
4.
Current/Recent Immigration Status
5.
Certificate of Naturalization or Citizenship Number
6.
Alien Registration Number (A-Number)
7.
Date of Birth
(mm/dd/yyyy)
8. Country
of
Birth
9.
IRS Tax Number ( if any)
10. U.S.
Social Security Number (if any)
Mailing
Address
12.a.
In Care Of Name
12.b.
Street Number and Name
12.c.
Apt. Ste. Flr.
12.d.
City or Town
12.e.
State
12.f.
Zip Code
12.g.
Postal Code
12.h.
Province
12.i.
Country
Physical
Address
11.a.
Street Number
and Name
11.b.
Apt. Ste. Flr.
11.c.
City or Town
11.d.
State
11.e.
Zip Code
11.f.
Postal Code
11.g.
Province
11.h.
Country
Contact
Information
13.
Daytime
Phone Number (if any) Extension
14.
Mobile Phone Number (if any)
15.
E-mail Address (if
any)
|
[Page 1],
Part
1.
Information
About You (Person
filing this Application)
[No
Change]
2.a.
Family Name
(Last
Name)
2.b.
Given Name
(First
name)
[No
Change]
3.
Company or Organization Name (if
any)
[Delete]
[No
Change]
NOTE:
If you are a U.S. citizen, type or print “N/A” for
Item
Number 4.
5.
Certificate of Naturalization or Citizenship Number (if
any)
6.
Alien Registration Number (A-Number) (if
any)
7.
Date of Birth
(mm/dd/yyyy)
[No
Change]
9.
Country of Citizenship or Nationality
10.
IRS Tax
Number (if any)
11.
U.S. Social
Security Number (if any)
[New]
12.
USCIS ELIS Account Number (if any)
Mailing
Address [Sub-header]
13.a.
In Care Of Name
13.b.
Street Number and Name
13.c.
Apt. Ste. Flr.
13.d.
City or Town
13.e.
State
13.f.
ZIP
Code
13.g.
Province
13.h.
Postal
Code
13.i.
Country
Physical
Address [Sub-header]
14.a.
Street Number
and Name
14.b.
Apt. Ste. Flr.
14.c.
City or Town
14.d.
State
14.e.
ZIP
Code
14.f.
Province
14.g.
Postal
Code
14.h.
Country
[Moved
to Part 4.]
[Moved
to Part 4.]
[Moved
to Part 4.]
[Moved
to Part 4.]
|
Page 2,
Part
2. Reason for Request
|
I
am requesting
(select
one):
a.
A duplicate approval notice.
b.
[] USCIS to notify a new U.S. Consulate, different from that
originally requested, through the U.S. Department of State's
National Visa Center or Kentucky Consular Center about the
approval of a nonimmigrant visa petition or to notify a new
Port-of-Entry, different from that originally requested, about the
approval of a waiver application. Please notify the U.S. Consulate
or Port-of-Entry at:
c.
[] USCIS to notify a U.S. Consulate through the National Visa
Center that I adjusted status to permanent resident in
the U.S. Please notify the U.S. Consulate at:
so
that my spouse and/or child(ren) may accompany or follow-to-join
me.
d.
USCIS to send my approved immigrant visa petition to the National
Visa Center (NVC).
e.
USCIS to notify the U.S. Department of State that I have become a
U.S. Citizen through naturalization.
|
[Page 2],
Part
2. Reason for Request
I
am requesting
(select
only
one):
1.a.
A duplicate
approval notice.
1.b.
U.S.
Citizenship and Immigration Services (USCIS)
to notify a new U.S. Consulate, different from the
one that I
originally requested, through the U.S. Department of State's
National Visa Center (NVC)
or Kentucky
Consular Center.
USCIS will notify the U.S. Consulate
about the approval of a nonimmigrant visa petition or about
a new
Port-of-Entry (the
Port-of-Entry is different
from what
I originally
requested)
about the approval of a waiver application. Please notify the U.S.
Consulate or Port-of-Entry at:
1.c.
USCIS to notify
a U.S. Consulate through the NVC about
my adjustment
of status to permanent resident in the United
States.
Please
notify the U.S. Consulate at:
so that my spouse and/or
children may accompany or follow-to-join me.
1.d.
USCIS to send
my approved immigrant visa petition to the NVC.
1.e.
USCIS to notify
the U.S. Department of State that I have become a U.S. citizen
through naturalization.
|
Page 2,
Part
3. Additional Information
|
Provide
the following information about the principal beneficiary of the
previous application or petition.
1.a.
Form Number of
Application or Petition
1.b.
Receipt Number
(On Form I-797,
Notice of Action)
1.c.
Filing
Date of Application or Petition (mm/dd/yyy)
1.d.
Approval
Date (mm/dd/yyyy)
Provide
the following information about the principal beneficiary of the
previous application or petition.
2.a.
Family Name
(Last Name)
2.b.
Given Name
(First name)
2.c.
Middle Name
2.d.
Date of Birth (mm/dd/yyyy)
2.e.
Country of
Birth
2.f.
Alien Registration Number (A-Number)
2.g.
Daytime Phone Number (if any) Extension
Mailing
Address
4.a.
In Care Of Name
4.b.
Street Number and Name
4.c.
Apt. Ste. Flr.
4.d.
City or Town
4.e.
State
4.f.
Zip Code
4.g.
Postal Code
4.h.
Province
4.i.
Country
Physical Address
3.a. Street
Number
and
Name
3.b.
Apt. Ste. Flr.
3.c.
City or Town
3.d.
State
3.e.
Zip Code
Dependents
If
you
selected
Box
"c"
in
Part
2.
Reason
for
Request,
provide the
following
information
about
the
dependent(s)
for
whom
you are
requesting
follow-to-join.
If
you
need
additional
space
for your
dependents,
attach
a
separate
sheet(s)
of
paper
and
include all
the
information
collected
in
Items
Number
5.a.
-
10.
5.a.
Family Name
(Last Name)
5.b.
Given Name
(First name)
5.c.
Middle Name
5.d.
Date of Birth (mm/dd/yyyy)
5.e.
Country of Birth
5.f.
Country of Citizenship
5.g.
Relationship
to Principal Alien
________________________________
6.a.
Family Name
(Last Name)
6.b.
Given Name
(First name)
6.c.
Middle Name
6.d.
Date of Birth (mm/dd/yyyy)
6.e.
Country of Birth
6.f.
Country of Citizenship
6.g.
Relationship
to Principal Alien
___________________________________
7.a.
Family Name
(Last Name)
7.b.
Given Name
(First name)
7.c.
Middle Name
7.d.
Date of Birth (mm/dd/yyyy)
7.e.
Country of Birth
7.f.
Country of Citizenship
7.g.
Relationship
to Principal Alien
___________________________________
8.a.
Family Name
(Last Name)
8.b.
Given Name
(First name)
8.c.
Middle Name
8.d.
Date of Birth (mm/dd/yyyy)
8.e.
Country of Birth
8.f.
Country of Citizenship
8.g.
Relationship
to Principal Alien
9.a.
In Care Of Name
9.b.
Street Number and Name
9.c.
Apt. Ste. Flr.
9.d.
City or Town
9.g.
Postal Code
9.h.
Province
9.i.
Country
10.
Foreign
Telephone Number Extension
|
[Page 2],
Part
3. Other
Information
Provide
the following information about the principal beneficiary of the
previous application or petition,
if other than you.
[No
Change]
1.b.
Receipt Number
(On
Form I-797, Notice of Action)
1.c.
Filing
Date of Application or Petition (mm/dd/yyy)
1.d.
Approval
Date (mm/dd/yyyy)
[No
Change]
2.a.
Family Name
(Last
Name)
2.b.
Given Name
(First
name)
2.c.
Middle Name
2.d.
Date of Birth (mm/dd/yyyy)
[No
Change]
2.f.
Alien Registration Number (A-Number) (if any)
2.g.
Daytime
Telephone Number
Mailing
Address [Sub-header]
3.a.
In Care Of Name
3.b.
Street Number and Name
3.c.
Apt. Ste. Flr.
3.d.
City or Town
3.e.
State
3.f.
ZIP
Code
3.g.
Province
3.h.
Postal Code
3.i.
Country
Physical Address
[Sub-header]
4.a.
Street
Number
and
Name
4.b.
Apt. Ste. Flr.
4.c.
City or Town
4.d.
State
4.e.
ZIP
Code
4.f.
Province
4.g.
Postal Code
4.h.
Country
Dependents
[Sub-header]
If
you selected Part
2., Item
Number 1.c.,
provide the following information about the dependents for whom
you are requesting follow-to-join benefits.
If you need additional space for your dependents, use
the space provided in Part
7. Additional Information,
and include all the information collected in Item
Numbers
5.a. - 11.
5.a.
Family Name
(Last
Name)
5.b.
Given Name
(First
Name)
[No
Change]
6.
Date of Birth (mm/dd/yyyy)
7.
Country of
Birth
8.
Country
of Citizenship
or
Nationality
9.
Relationship
to Principal Applicant
10.
Dependent’s Email Address (if any)
11.
Dependent’s Daytime Telephone Number
___________________________________
12.a.
Family Name
(Last
Name)
12.b.
Given Name
(First
Name)
12.c.
Middle
Name
13.
Date of Birth (mm/dd/yyyy)
14.
Country of Birth
15.
Country
of Citizenship
or
Nationality
16.
Relationship
to Principal Applicant
17.
Dependent’s Email Address (if any)
18.
Dependent’s Daytime Telephone Number
___________________________________
19.a.
Family Name
(Last
Name)
19.b.
Given Name
(First
Name)
19.c.
Middle
Name
20.
Date of Birth (mm/dd/yyyy)
21.
Country of Birth
22.
Country
of Citizenship
or
Nationality
23.
Relationship
to Principal Applicant
24.
Dependent’s Email Address (if any)
25.
Dependent’s Daytime Telephone Number
___________________________________
26.a.
Family Name
(Last
Name)
26.b.
Given Name
(First
Name)
26.c.
Middle
Name
27.
Date of Birth (mm/dd/yyyy)
28.
Country of Birth
29.
Country
of Citizenship
or
Nationality
30.
Relationship
to Principal Applicant
31.
Dependent’s Email Address (if any)
32.
Dependent’s Daytime Telephone Number
Foreign
Address of
Dependents
[Sub-header
33.a.
In Care Of Name
33.b.
Street Number and Name
33.c.
Apt. Ste. Flr.
33.d.
City or Town
33.e.
Province
33.f.
Postal Code
33.i.
Country
Contact
Information of
Dependents
[Sub-header]
34.
Foreign
Telephone Number
|
Page 4,
Part
4. Signature of Applicant
|
(Read
the information on penalties in the Form I-824 instructions before
completing this part.)
I
certify,
under
penalty
of
perjury
under
the
laws
of
the
United
States
of
America,
that
this
application
and
the
evidence
submitted
with
it
are
all
true
and
correct
to
the
best
of
my
knowledge
and
abilities.
I
authorize
the
release
of
any
information
from
my
records
that
U.S.
Citizenship
and
Immigration
Services
(USCIS)
needs
to
determine
my
eligibility
for
this
benefit.
I
furthermore authorize release of information contained in this
form, supporting documents, and my USCIS records to other entities
and persons where necessary for the administration of U.S.
immigration laws.
1.a.
Signature
of Applicant
1.b.
Date of
Signature (mm/dd/yyyy)
NOTE:
If you do not
completely fill out this form or fail to submit required documents
listed in the instructions, your application may be denied.
|
[Page 4],
Part
4.
Applicant’s
Statement,
Contact Information, Certification, and Signature
NOTE:
Read the information on penalties
in
the Penalties
section of the Form I-824 Instructions before completing this
part.
[New]
Applicant’s
Statement [Sub-header]
NOTE:
Select the box for either Item
Number 1.a. or 1.b.
If applicable, select the box for Item
Number 2.
1.a.
[] I can read and understand English, and have read and
understand every question and instruction on this application,
as well as my
answer to every question.
1.b.
[]
The interpreter named in Part
5. has
also read to me every
question and instruction on this application, as well as my answer
to every question, in _______________________, a language in which
I am fluent. I understand every question and instruction on this
application
as translated to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated above.
2.
[] I have requested the services of and consented to
________________________, who []
is
[]
is
not an attorney or accredited representative, preparing this
application
for me.
Applicant’s
Contact
Information
[Sub-header]
3.
Applicant’s Daytime
Telephone Number
4.
Applicant’s Mobile
Telephone Number (if any)
5.
Applicant’s Email
Address (if any)
Applicant’s
Certification [Sub-header]
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
application,
in supporting documents, and in my USCIS records to other entities
and persons where necessary for the administration and enforcement
of U.S. immigration laws.
I
certify, under penalty of perjury, that the information in my
application
and any document submitted with my application
were provided by me and are complete, true, and correct.
[See
above]
Applicant’s
Signature
[Sub-header]
6.a.
Applicant’s Signature
6.b.
Date
of Signature (mm/dd/yyyy)
NOTE
TO ALL APPLICANTS: If
you do not completely fill out this application or fail to submit
required documents listed in the Instructions, USCIS may deny your
application.
|
NEW
|
|
Page 4,
[New]
Part
5.
Interpreter’s Contact Information,
Certification,
and Signature
Provide
the following information about the interpreter.
Interpreter’s
Full Name [Sub-header]
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 [Sub-header]
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 [Sub-header]
4.
Interpreter’s Daytime Telephone Number
5.
Interpreter’s Email Address (if any)
Interpreter’s
Certification [Sub-header]
I
certify that:
I
am fluent in English and ________________,
which
is the same language provided in Part
4.,
Item
Number 1.b.;
I
have read to this applicant every question and instruction on this
application,
as well as the answer to every question, in the language provided
in Part
4.,
Item
Number 1.b.;
and
The
applicant has informed me that he or she understands every
instruction and question on the application,
as well as the answer to every question, and the applicant
verified
the accuracy of every answer.
Interpreter’s
Signature [Sub-header]
6.a.
Interpreter’s Signature
6.b.
Date of Signature (mm/dd/yyyy)
|
Page 4
|
Part
5. Signature of Person Preparing This
Form, If Other
Than the Applicant
NOTE:
If you are an
attorney or a BIA-Accredited Representative, you must submit a
completed Form G-28, Notice of Entry of Appearance as Attorney or
Accredited Representative, along with this application.
Preparer's
Information
Provide
the following information concerning the preparer:
1.a.
Preparer's
Family Name (Last
Name)
1.b.
Preparer's
Given Name (First
Name)
2.
Preparer's
Business or Organization Name
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.
Postal Code
3.g.
Province
3.h.
Country
Preparer's
Contact Information
4.
Preparer's
Daytime Phone Number Extension
5.
Preparer's
E-mail Address (if
any)
Declaration
I
declare
that
this
document
was
prepared
by
me
at
the
request
of
the
applicant
or
other
individual
authorized
by
the
form
instructions
to
sign
this
application
(see
the
instructions),
and
it
is
based
on
all
information
of
which
I
have
knowledge
and/or
was
provided
to
me
by
the
above
named
person
in
response
to
the
exact
questions
contained
on
this
form.
I
have
not
knowingly
withheld
any
information.
6.a.
Signature of
Preparer
6.b.
Date of
Signature (mm/dd/yyyy)
|
[Page 5],
Part
6.
Contact Information, Statement, Certification, and Signature of
the Person Preparing this Application, If Other Than the Applicant
[See
below]
Provide
the following information about
the preparer.
Preparer’s
Full Name [Sub-header]
[See
above]
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 [Sub-header]
[No
change]
[No
change]
[No
change]
[No
change]
3.e.
ZIP Code
3.f.
Province
3.g.
Postal Code
[No
change]
Preparer's
Contact Information
[Sub-header]
4.
Preparer's
Daytime Telephone Number
5.
Preparer’s Fax Number
6.
Preparer's
Email Address (if any)
[New]
Preparer’s
Statement
[Sub-header]
7.a.
[] I
am not an attorney or accredited representative but have prepared
this application on behalf of the applicant
and
with the applicant’s
consent.
7.b.
[] I
am an attorney or accredited representative and my representation
of the applicant
in
this case
[] extends [] does not extend
beyond
the preparation of this application.
NOTE:
If
you are an attorney or accredited representative whose
representation extends beyond preparation of this application, you
must submit a completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative or G-28I, Notice of Entry
of Appearance as Attorney In Matters Outside of the Geographical
Confines of the United States, with this application.
Preparer’s
Certification [Sub-header]
By
my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this application
on behalf of, at the request of, and with the express consent of
the applicant. I completed this application
based only on responses the applicant provided to me. After
completing the application, I reviewed it and all of the
applicant’s responses with the applicant, who agreed with
every answer on the application. If the applicant supplied
additional information concerning a question on the application, I
recorded it on the application.
Preparer’s
Signature [Sub-header]
8.a.
Preparer’s Signature
8.b.
Date of Signature (mm/dd/yyyy)
|
NEW
|
|
[Page
7],
[New]
Part
7. Additional Information
If
you need extra space to provide any additional information within
this application,
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 application
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.
___________________________________
|