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pdfUSCIS
Form I-941
Application for Entrepreneur Parole
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-NEW
Expires 00/00/20xx
Receipt
For
USCIS
Use
Only
Action Block
DRAFT
NOT FOR
PRODUCTION
08/24/2016
Remarks
To be completed by an
attorney or accredited
representative (if any).
Select this box if
Form G-28 or
G-28I is attached.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
► START HERE - Type or print in black ink.
Part 1. Information About the Entrepreneur
(Applicant)
I am requesting:
1.a.
Initial Parole
OR
1.b.
Re-Parole
OR
1.c.
Amended Application
If you are requesting a re-parole or filing an amended application,
provide the Receipt Number of your current Form I-941 approval
in Item Number 2. below.
2.
Receipt Number
►
Your Full Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name
Other Names Used
Provide any other names you have used since birth, including
aliases, maiden names, and nicknames. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c. Middle Name
Other Information
5.
Alien Registration Number (A-Number)
► A-
6.
USCIS Online Account Number (if any)
►
7.
U.S. Social Security Number (if any)
►
8.
Date of Birth (mm/dd/yyyy)
9.
Sex
10.
Marital Status
Single
Form I-941 09/03/15
Male
Married
Female
Divorced
Widowed
Page 1 of 15
Where do you want USCIS to send all travel documents for
you, and your spouse and dependent children (if applicable)?
Part 1. Information About the Entrepreneur
(Applicant) (continued)
11.
18.a.
To the U.S. address in Part 1., Item Numbers
19.a. - 19.f.
18.b.
To a U.S. Embassy or U.S. Consulate at:
Country of Birth
12.
Country of Citizenship or Nationality
13.
Date of Last Arrival in the United States (if any)
(mm/dd/yyyy)
14.
Current or Last Class of Admission (if any) (for example,
B-1, F-1, H-1B)
15.
If you are present in the United States, other than on the
basis of an Entrepreneur Parole, provide the receipt number
of your most recent filing with USCIS (if applicable).
Name of U.S. Embassy or U.S. Consulate
18.c.
To a Department of Homeland Security (DHS) office
overseas at:
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►
Name of DHS Office
Entrepreneur's Current U.S. Mailing Address
19.a. In Care Of Name
19.b. Street Number
and Name
Provide information about your most recent Form I-94 ArrivalDeparture Record, in Item Numbers 16.a. - 16.f. (if any).
19.c.
16.a. Form I-94 Arrival-Departure Record Number
►
19.d. City or Town
Apt.
Ste.
19.e. State
16.b. Passport Number
Flr.
19.f. ZIP Code
Entrepreneur's Current Physical Address
16.c. Travel Document Number (if any)
20.a. Street Number
and Name
16.d. Country of Issuance for Passport or Travel Document
20.b.
Apt.
Ste.
Flr.
20.c. City or Town
16.e. Expiration Date for Passport or Travel Document
20.d. State
(mm/dd/yyyy)
20.e. ZIP Code
20.f. Province
16.f. Date that Authorized Stay Expired or Will Expire as
Shown on Form I-94 or I-95 (mm/dd/yyyy)
20.g. Postal Code
17.a. Have you, or any person included in this application, ever
been in exclusion, deportation, removal, or rescission
proceedings, or are you now in such proceedings?
Yes
No
If you answered "Yes," to Item Number 17.a., provide
the following information below:
17.b. Name of the Person in Proceedings
Form I-941 09/03/15
20.h. Country
Entrepreneur's Education
21.
Name of Institution of Higher Learning
22.
Type of Degree/Major Field of Study
23.
Date Degree Received (mm/dd/yyyy)
Page 2 of 15
Part 1. Information About the Entrepreneur
(Applicant) (continued)
Part 3. Information About Family Members
Requesting Parole or Re-Parole with
Entrepreneur
School Address
Entrepreneur's Spouse's Information
24.a. Street Number
and Name
24.b.
Apt.
Ste.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
Flr.
24.c. City or Town
24.d. State
1.c. Middle Name
24.e. ZIP Code
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2.
24.f. Province
► A-
24.g. Postal Code
24.h. Country
A-Number (if any)
3.
USCIS Online Account Number (if any)
►
4.
Date of Birth (mm/dd/yyyy)
5.
Country of Birth
6.
Country of Citizenship or Nationality
Part 2. Biographic Information
1.
Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino
2.
Entrepreneur's Spouse's Other Names Used
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
4.
Weight
5.
Eye Color (Select only one box)
Blue
Green
Pink
Brown
Hazel
Unknown/Other
Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy
7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)
7.c. Middle Name
Pounds
Black
Gray
Maroon
6.
Inches
Provide any other names your spouse has used since birth,
including aliases, maiden names, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
Black
Gray
White
Entrepreneur's Dependent Children
Provide the following information about each child. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
Child 1
Blond
Red
Unknown/Other
8.a. Family Name
(Last Name)
8.b. Given Name
(First Name)
8.c. Middle Name
Form I-941 09/03/15
Page 3 of 15
Part 3. Information About Family Members
Requesting Parole or Re-Parole with
Entrepreneur (continued)
4.
9.
Entrepreneur 2
A-Number (if any)
► A-
10.
USCIS Online Account Number (if any)
►
Receipt Number (if applicable)
►
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
11.
Date of Birth (mm/dd/yyyy)
12.
Country of Birth
13.
6.
Date of Birth (mm/dd/yyyy)
7.
Country of Citizenship or Nationality
8.
Receipt Number (if applicable)
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Country of Citizenship or Nationality
►
Child 2
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners
Information About the Qualifying Start-Up Entity
14.c. Middle Name
15.
A-Number (if any)
1.
Start-Up Entity Legal Name
► A-
16.
USCIS Online Account Number (if any)
►
Start-Up Entity Address
2.a. Street Number
and Name
Apt.
17.
Date of Birth (mm/dd/yyyy)
2.b.
18.
Country of Birth
2.c. City or Town
19.
Country of Citizenship or Nationality
Part 4. Information About Additional
Entrepreneurs Requesting Parole or Re-Parole
with the Same Start-Up Entity
2.d. State
Ste.
Flr.
2.e. ZIP Code
3.
Federal Employer Identification Number
4.
DUNS Number (if any)
5.
Trade Name "DBA" (Doing Business As)
6.
Date Start-Up Entity Established in United States
Entrepreneur 1
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
(mm/dd/yyyy)
7.
Number of Full-Time Employees in United States
8.
Your Ownership Stake/Percentage of Start-Up Entity
1.c. Middle Name
2.
Date of Birth (mm/dd/yyyy)
3.
Country of Citizenship or Nationality
Form I-941 09/03/15
%
Page 4 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
Applying for Initial Parole
9.
Explanatory Statement. Provide a detailed statement
explaining how you meet the criteria for entrepreneur
parole. Your statement should include an explanation of
your role in the operations of that entity, as well as how
your involvement with the start-up entity will advance the
start-up entity's growth and business success such as to
result in a significant public benefit. You may provide this
statement in the space provided in Part 10. Additional
Information or attach a separate sheet of paper; type or
print your name and startup entity identification number 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.
Alternative Criteria
12.a. Does your start-up entity partially meet one or more of the
above threshold criteria?
Yes
No
N/A
If you answered "Yes" to Item Number 12.a., provide
the amounts of qualified investment and/or qualified
government award or grant that was received in Item
Numbers 12.b. - 12.c.
12.b. Amount of Qualified Investment
$
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12.c. Amount of Qualified Government Award or Grant
$
Applying for Re-Parole
13.
Is this the same start-up entity for which you were granted
an initial parole?
Yes
No
If you answered "No" to Item Number 13., explain the
current status of the start-up entity for which you were
granted initial parole in Item Number 14. If you need
more space to complete this section, use the space
provided in Part 10. Additional Information.
14.
Explanation
10.a. Did your start-up entity receive a qualified investment of
at least $345,000 within the 365 days immediately
preceding the filing of this application?
Yes
No
If you answered "Yes" to Item Number 10.a., provide
the amount of qualified investment and date the qualified
investment was received in Item Numbers 10.b. - 10.c.
10.b. Amount of Qualified Investment
$
10.c. Date Qualified Investment Received (mm/dd/yyyy)
11.a. Did your start-up entity receive a qualified government
award or grant of at least $100,000 within the 365 days
immediately preceding the filing of this application?
Yes
No
Re-Parole Criteria
Provide evidence that you continue to meet the definition of
entrepreneur and that your business continues to meet the
definition of start-up entity.
15.
Do you own at least 10 percent of the shares, or similar
type of equity interest, in the start-up entity?
Yes
If you answered "Yes" to Item Number 11.a., provide
the amount of qualified government award or grant and
date the qualified government award or grant was
received in Item Numbers 11.b. - 11.c.
11.b. Amount of Qualified Government Award or Grant
No
16.
Do you continue to perform an active and central role in
the start-up entity?
Yes
No
17.
Is the start-up entity continuing to lawfully operate in the
United States?
Yes
No
$
11.c. Date Qualified Grant or Award Received (mm/dd/yyyy)
Form I-941 09/03/15
Page 5 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
23.
18.a. Did your start-up entity receive at least $500,000 in
qualifying investments during the initial parole period?
Yes
No
N/A
18.b. Provide the amounts of qualifying investments.
$
19.a. Did your start-up entity create at least 10 qualified jobs
with the start-up entity during the initial parole period?
Provide a detailed statement explaining how you continue
to meet the criteria for entrepreneur parole. Your statement
should include an explanation of your continued or new
role in the operations of that entity, as well as how your
involvement with the start-up entity will advance the startup entity's growth and business success such as to result in
a significant public benefit. You may provide this
statement in the space provided in Part 10. Additional
Information or attach a separate sheet of paper; type or
print your name and startup entity identification number 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.
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Yes
No
N/A
19.b. Provide the number of qualified jobs.
20.a. Did your start-up reach at least $500,000 in annual revenue
during the initial parole period?
Yes
No
N/A
20.b. Provide the amount of annual revenue generated.
$
21.a. Did the annual revenue generated by your start-up entity
average 20 percent growth during the initial parole period?
Yes
No
N/A
21.b. Provide the percentage of annual revenue growth.
%
24.a. Are you maintaining a household income that is greater
than 400 percent of the Federal Poverty Guidelines?
Alternative Criteria
22.b. Total Amount of Revenue Generated During Current
Period of Parole
$
22.c. Total Amount of Additional Qualified Investment During
Current Period of Parole
$
22.d. Total Number of Qualified Jobs Created During Current
Period of Parole
24.b. Amount of Household Income in Last Full Calendar Year
$
24.c. Number of Members of Household
Filing an Amended Application to Report a
Material Change
In the space below, provide a detailed explanation of any material
changes to the facts on which your or your family's parole was
based. If you need more space to complete this section, use the
space provided in Part 10. Additional Information.
25.
Form I-941 09/03/15
No
If you answered "Yes" to Item Number 24.a., provide
the information requested in Item Numbers 24.b. - 24.c.
22.a. Does your start-up entity partially meet one or more of the
above threshold criteria?
Yes
No
N/A
If you answered "Yes" to Item Number 22.a., provide
the applicable information requested in Item Numbers
22.b. - 22.d.
Yes
Explanation
Page 6 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
31.
26.a. Are you maintaining a household income that is greater
than 400 percent of the Federal Poverty Guidelines?
32.
Date of Birth (mm/dd/yyyy)
33.
Country of Birth
34.
Country of Citizenship or Nationality
Yes
No
If you answered "Yes" to Item Number 26.a., provide
the information requested in Item Numbers 26.b. - 26.c.
USCIS Online Account Number (if any)
►
26.b Amount of Household Income in Last Full Calendar Year
$
35.a. Percentage of Ownership in the Start-Up Entity Listed in
Part 5., Item Number 1.
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26.c. Number of Members of Household
Information About the Owners of the Start-Up
Entity
35.b. Position Held (if any) in the Entity Listed in Part 5., Item
Number 1.
If there are multiple owners of the start-up entity, you must list
all other individuals or entities that own a share of the start-up
entity and identify their ownership percentage.
Address and Contact Information
Owner 1
36.a. Street Number
and Name
36.b.
27.a. Family Name
(Last Name)
27.b. Given Name
(First Name)
Apt.
Ste.
Flr.
36.c. City or Town
36.d. State
27.c. Middle Name
27.d. Legal Entity Name (if any)
36.e. ZIP Code
36.f. Province
36.g. Postal Code
27.e. Trade Name "DBA" (Doing Business As)
Other Names Used
Provide any other names you have used since birth, including
aliases, maiden names, and nicknames. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.
28.a. Family Name
(Last Name)
28.b. Given Name
(First Name)
36.h. Country
37.
Daytime Telephone Number
38.
Fax Number
39.
Email Address (if any)
40.
Website Address (if any)
28.c. Middle Name
Owner 2
Other Information
29.
A-Number (if any)
► A-
30.
U.S. Social Security Number (if any)
►
Form I-941 09/03/15
41.a. Family Name
(Last Name)
41.b. Given Name
(First Name)
41.c. Middle Name
Page 7 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
41.d. Legal Entity Name (if any)
Address and Contact Information
50.a. Street Number
and Name
50.b.
41.e. Trade Name "DBA" (Doing Business As)
Apt.
Ste.
50.c. City or Town
50.d. State
Other Names Used
Flr.
50.e. ZIP Code
50.f. Province
Provide any other names used for Owner 2 since birth,
including aliases, maiden name, and nicknames. If extra space
is needed to complete this section, use the space provided in
Part 10. Additional Information.
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50.g. Postal Code
50.h. Country
42.a. Family Name
(Last Name)
42.b. Given Name
(First Name)
51.
Daytime Telephone Number
42.c. Middle Name
52.
Fax Number
Other Information
53.
Email Address (if any)
54.
Website Address (if any)
43.
A-Number (if any)
► A-
44.
U.S. Social Security Number (if any)
►
45.
USCIS Online Account Number (if any)
►
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
46.
Date of Birth (mm/dd/yyyy)
Name of Investor (if an individual)
47.
Country of Birth
48.
Country of Citizenship or Nationality
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
49.a. Percentage of Ownership in the Start-Up Entity Listed in
Part 5., Item Number 1.
49.b. Position Held (if any) in the Entity Listed in Part 5., Item
Number 1.
2.
Date of Birth (mm/dd/yyyy)
3.
A-Number (if any)
► A-
4.
U.S. Social Security Number (if any)
►
5.
Form I-941 09/03/15
Country of Birth
Page 8 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
List all investments in other start-ups by this investor during the
preceding five years. If you need extra space to complete this
section, use the space provided in Part 10. Additional
Information.
Mailing Address and Contact Information
14.
Name of Company
15.
DUNS Number (if any)
16.
Year of Investment
6.a. Street Number
and Name
6.b.
Apt.
Ste.
Flr.
6.c. City or Town
6.d. State
6.f.
Province
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6.e. ZIP Code
6.g. Postal Code
6.h. Country
17.
Amount of Investment $
18.
Type of Investment
19.a. Street Number
and Name
19.b.
7.
Daytime Telephone Number
8.
Fax Number
Apt.
Ste.
Flr.
19.c. City or Town
19.d. State
19.e. ZIP Code
19.f. Province
9.
Email Address (if any)
10.
Website Address (if any)
19.g. Postal Code
19.h. Country
Information on Investment
11.a. Aggregate Amount of Investment
$
11.b. Types of Investment (for example, equity or convertible
debt)
Identify at least 2 of the start-ups listed above that each created,
subsequent to such investment, at least 5 qualified jobs or
generated at least $500,000 in revenue with average annualized
revenue growth of at least 20 percent.
Company 1
20.
Name of Company
21.
DUNS Number (if any)
Qualified Investor Verification
12.
Is the investor a U.S. citizen or lawful permanent resident
of the United States?
Yes
No
13.
Has the investor been permanently or temporarily enjoined
from participating in the offer or sale of a security or in the
provision of services as an investment adviser, broker,
dealer, municipal securities dealer, government securities
broker, government securities dealer, bank, transfer agent
or credit rating agency; barred from association with any
entity involved in the offer or sale of securities or provision
of such services; or otherwise found to have participated in
the offer or sale of securities or provision of such services
in violation of law?
Yes
No
Form I-941 09/03/15
Page 9 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
Apt.
Ste.
Flr.
Apt.
22.d. State
22.e. ZIP Code
Ste.
Flr.
27.c. City or Town
27.d. State
22.c. City or Town
22.f. Province
27.a. Street Number
and Name
27.b.
22.a. Street Number
and Name
22.b.
Address and Contact Information
27.e. ZIP Code
27.f. Province
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27.g. Postal Code
27.h. Country
22.g. Postal Code
22.h. Country
Company 2
23.
24.
28.
Daytime Telephone Number
29.
Fax Number
30.
Email Address (if any)
31.
Website Address (if any)
Name of Company
DUNS Number (if any)
25.a. Street Number
and Name
25.b.
Apt.
Ste.
Flr.
Information on Investment
32.a. Aggregate Amount of Investment
25.c. City or Town
25.d. State
25.f. Province
$
25.e. ZIP Code
32.b. Types of Investment (for example, equity or
convertible debt)
25.g. Postal Code
25.h. Country
Name of Investor (if an organization such as a
Venture Capital Firm, Accelerator or Incubator)
26.a. Legal Entity Name
26.b. Trade Name "DBA" (Doing Business As)
26.c. DUNS Number (if any)
Form I-941 09/03/15
Qualified Investor Verification
33.
Is the investor majority owned and controlled, directly
and indirectly, by U.S. citizens or lawful permanent
residents of the United States?
Yes
No
34.
Has the investor been permanently or temporarily
enjoined from participating in the offer or sale of a
security or in the provision of services as an investment
adviser, broker, dealer, municipal securities dealer,
government securities broker, government securities
dealer, bank, transfer agent or credit rating agency; barred
from association with any entity involved in the offer or
sale of securities or provision of such services; or
otherwise found to have participated in the offer or sale of
securities or provision of such services in violation of
law?
Yes
No
Page 10 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
43.a. Street Number
and Name
List all investments in other start-ups by this investor during the
preceding five years. If you need extra space to complete this
section, use the space provided in Part 10. Additional
Information.
43.c. City or Town
35.
43.b.
Apt.
Ste.
43.d. State
Flr.
43.e. ZIP Code
43.f. Province
Name of Company
43.g. Postal Code
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36.
DUNS Number (if any)
43.h. Country
37.
Year of Investment
38.
Amount of Investment $
39.
Type of Investment
Company 2
Address Information
Apt.
Name of Company
45.
DUNS Number (if any)
46.a. Street Number
and Name
40.a. Street Number
and Name
40.b.
44.
46.b.
Ste.
Apt.
Ste.
Flr.
Flr.
46.c. City or Town
40.c. City or Town
46.d. State
40.d. State
46.e. ZIP Code
40.e. ZIP Code
46.f. Province
40.f. Province
46.g. Postal Code
40.g. Postal Code
40.h. Country
46.h. Country
Identify at least 2 of the start-ups listed above that each created,
subsequent to such investment, at least 5 qualified jobs or
generated at least $500,000 in revenue with average annualized
revenue growth of at least 20 percent.
Company 1
41.
Name of Company
42.
DUNS Number (if any)
Form I-941 09/03/15
Page 11 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
Name of Government Entity Providing Grant/Award
NOTE: Read the Penalties section of the Form I-941
Instructions before completing this part. You must file Form
I-941 while in the United States.
47.
Name of Approving Official
Applicant's Statement
Address and Contact Information
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48.a. Street Number
and Name
48.b.
Apt.
Ste.
48.f. Province
49.
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.b.
The interpreter named in Part 8. read to me every
question and instruction on this application and my
answer to every question in
48.e. ZIP Code
,
a language in which I am fluent, and I understood.
2.
48.g. Postal Code
48.h. Country
1.a.
Flr.
48.c. City or Town
48.d. State
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
At my request, the preparer named in Part 9.,
,
prepared this application for me based upon
information I provided or authorized.
Daytime Telephone Number
Applicant's Contact Information
50.
Fax Number
51.
Email Address (if any)
52.
Website Address (if any)
Information on Grant/Award
53.a. Aggregate of Amount of Grant/Award
$
53.b. Types of Grant/Award
3.
Applicant's Daytime Telephone Number
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
Applicant's Declaration and 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
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 law.
Form I-941 09/03/15
Page 12 of 15
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct
at the time of filing.
Interpreter's Mailing Address
3.a. Street Number
and Name
3.b.
Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
3.e. ZIP Code
Province
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I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.
3.g. Postal Code
3.h. Country
Interpreter's Contact Information
4.
Interpreter's Daytime Telephone Number
5.
Interpreter's Mobile Telephone Number (if any)
6.
Interpreter's Email Address (if any)
Applicant's Signature
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. USCIS
will issue a notice of intent to terminate your participation in the
Significant Public Benefit Entrepreneur Program if a start-up
entity fails to submit the required information or upon a
determination that the start-up entity no longer serves the
purpose of promoting economic growth.
Part 8. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 7., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
Provide the following information about the interpreter.
Interpreter's Signature
Interpreter's Full Name
7.a. Interpreter's Signature
1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.
7.b. Date of Signature (mm/dd/yyyy)
Interpreter's Business or Organization Name (if any)
Form I-941 09/03/15
Page 13 of 15
Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Statement
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.
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.
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Preparer's Business or Organization Name (if any)
NOTE: If applicable, provide the name of your accredited
organization recognized by the Board of Immigration Appeals
(BIA).
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.
Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.f.
Province
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, or Form
G-28I, Notice of Entry of Appearance as Attorney In
Matters Outside the Geographical Confines of the
United States, with this application.
3.e. ZIP Code
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.
Preparer's Signature
8.a. Preparer's Signature
3.g. Postal Code
3.h. Country
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Telephone Number
6.
Preparer's Email Address (if any)
Form I-941 09/03/15
Page 14 of 15
5.a. Page Number
Part 10. Additional Information
If you need extra space to provide any additional information
within this form, 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 form or attach a separate sheet of
paper. Type or print the start-up entity's name 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.
Name of Start-Up Entity
2.
Start-Up Entity Identification Number
5.d.
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3.a. Page Number
3.d.
5.b. Part Number 5.c. Item Number
3.b. Part Number
3.c. Item Number
6.a. Page Number
6.d.
7.a. Page Number
4.a. Page Number
6.b. Part Number 6.c. Item Number
7.b. Part Number 7.c. Item Number
4.b. Part Number 4.c. Item Number
7.d.
4.d.
Form I-941 09/03/15
Page 15 of 15
| File Type | application/pdf |
| File Title | Application for Significant Public Benefit Entrepreneur |
| Author | USCIS |
| File Modified | 2016-08-24 |
| File Created | 2016-08-24 |