Table of Changes I-130 Form

TABLE OF CHANGES – FORM

FORM I-130, Petition for Alien Relative

OMB No: 1615-0012

05/12/2016

Reason for Revision

• U.S. Customs and Border Protection (CBP) has stopped issuing paper I-94 Arrival-Departure Records, except in limited circumstances, and will create an electronic record. The Form I-94 data will be available to entrants who have access to the internet to obtain their admission number and electronic I-94 record from the CBP Website at www.cbp.gov. Additional data collection fields are being incorporated into several USCIS forms to enable verification of status in the United States based upon passport or travel document details captured by CBP at the port of entry, rather than the I-94.

• ELIS Account Number data collections have been added for the petitioner, the beneficiary, and an attorney (if applicable), as well as any updates to the standard language since this form was last revised.

PAGE NUMBER AND SECTION	CURRENT VERSION	PROPOSED VERSION
Throughout Form	Two column and full page combined format	Full 2-column format and Online Account Number data collection added 1. The fields were changed such that the same information is captured, just in a revised layout that is an easier to read 2 column format for intake and filing purposes. The look of the data collection box format is new, and the form is longer due to the format revision. 2. The data collection box numbers have been changed in some instances throughout the form. (e.g., 1., 2., 3. to 1.a., 1.b., 1.c.). This was done to make the form more user friendly.
New		[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. Volag Number (if any) Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)
Page 1, Part A. Relationship	[Page 1] A. Relationship You are the petitioner. Your relative is the beneficiary. 1. I am filing this petition for my: Spouse / Parent Brother/Sister / Child 2. Are you related by adoption? Yes No 3. Did you gain permanent residence through adoption? Yes No	[Page 1] START HERE - Type or print in black ink. If you need extra space to complete any section of this petition, use the space provided in Part 9. Additional Information. Complete and submit as many copies of Part 9., as necessary, with your petition. Part 1. Relationship (You are the Petitioner. Your relative is the Beneficiary.) 1. I am filing this petition for my (Select only one box): Spouse Parent Brother/Sister Child 2. If you are filing this petition for your child or parent, select the box that describes your relationship (Select only one box): [ ] Child was born to parents who were married to each other at the time of the child’s birth [ ] Stepchild/Stepparent [ ] Child was born to parents who were not married to each other at the time of the child’s birth [ ] Child was adopted (not an Orphan or Hague Convention adoptee) 3. If the beneficiary is your brother/sister, are you related by adoption? Yes No 4. Did you gain lawful permanent resident status or citizenship through adoption? Yes No
Page 1, B. Information about you	[Page 1] B. Information about you 10. Alien Registration Number 9. U.S. Social Security Number (If any) 1. Name (Family name in CAPS) (First) (Middle) 7. Other Names Used (including maiden name) 3. Place of Birth (Town or City) (State/Country) 4. Date of Birth 5. Gender 2. Address (Number and Street) (Apt. No.) (Town or City) (State/Country) (Zip/Postal Code) 6. Marital Status Married Single Widowed Divorced 8. Date and Place of Present Marriage (if married) 11. Name(s) of Prior Spouse(s) 12. Date(s) Marriage(s) Ended 13. If you are a U.S. citizen, complete the following: My citizenship was acquired through (check one): Birth in the U.S. Naturalization. Give certificate number and date and place of issuance. Parents. Have you obtained a certificate of citizenship in your own name? Yes. Give certificate number, date and place of issuance. No 14. If you are a lawful permanent resident alien, complete the following: Date and place of admission for or adjustment to lawful permanent residence and class of admission. 14b. Did you gain permanent resident status through marriage to a U.S. citizen or lawful permanent resident?	[Page 1] Part 2. Information About You (Petitioner) 1. Alien Registration Number (A-Number) (if any) 2. USCIS Online Account Number (if any) 3. U.S. Social Security Number (if any) Your Full Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name [Page 2] Other Names Used (if any) Provide all other names you have ever used, including aliases, maiden name, and nicknames. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name Other Information 6. City/Town/Village of Birth 7. Country of Birth [delete] [delete] 8. Date of Birth (mm/dd/yyyy) 9. Sex Male Female Mailing Address 10.a. In Care Of Name 10.b. Street Number and Name 10.c. Apt. Ste. Flr. 10.d. City or Town 10.e. State 10.f. ZIP Code 10.g. Province 10.h. Postal Code 10.i. Country 11. Is your current mailing address the same as your physical address? Yes No If you answered “No” to Item Number 11., provide information on your physical address in Item Numbers 12.a. - 13.b. Address History Provide your physical addresses for the last five years, whether inside or outside the United States. Provide your current address first if it is different from your mailing address in Item Numbers 10.a. - 10.i. Physical Address 1 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 13.a. Date From (mm/dd/yyyy) 13.b. Date To (mm/dd/yyyy) Physical Address 2 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 15.a. Date From (mm/dd/yyyy) 15.b. Date To (mm/dd/yyyy) Your Marital Information [subheader] 16. How many times have you been married? 17. Current Marital Status Single, Never Married/Married/Divorced/ Widowed/Separated/Annulled [Page 3] 18. Date of Current Marriage (if currently married) (mm/dd/yyyy) Place of Your Current Marriage (if married) 19.a. City or Town 19.b. State 19.c. Province 19.d. Country Names of All Your Spouses (if any) Provide information on your current spouse (if currently married) first and then list all your prior spouses (if any). Spouse 1 20.a. Family Name (Last Name) 20.b. Given Name (First Name) 20.c. Middle Name 21. Date Marriage Ended (mm/dd/yyyy) Spouse 2 22.a. Family Name (Last Name) 22.b. Given Name (First Name) 22.c. Middle Name 23. Date Marriage Ended (mm/dd/yyyy) Information About Your Parents [subheader] Parent 1’s Information Full Name of Parent 1 24.a. Family Name (Last Name) 24.b. Given Name (First Name) 24.c. Middle Name 25. Date of Birth 26. Sex Male Female 27. Country of Birth 28. City/Town/Village of Residence 29. Country of Residence Parent 2’s Information Full Name of Parent 2 30.a. Family Name (Last Name) 30.b. Given Name (First Name) 30.c. Middle Name 31. Date of Birth 32. Sex Male Female 33. Country of Birth 34. City/Town/Village of Residence 35. Country of Residence Additional Information About You (Petitioner) 36. I am a (Select only one box): U.S. Citizen Lawful Permanent Resident If you are a U.S. citizen, complete Item Number 37. 37. My citizenship was acquired through (Select only one box): Birth in the United States Naturalization Parents 38. Have you obtained a Certificate of Naturalization or a Certificate of Citizenship? Yes/No If you answered "Yes" to Item Number 38., complete the following: 39.a. Certificate Number 39.b. Place of Issuance 39.c. Date of Issuance (mm/dd/yyyy) [Page 4] If you were admitted as or adjusted status to a lawful permanent resident, complete Item Numbers 40.a. - 41. 40.a. Class of Admission 40.b. Date of Admission (mm/dd/yyyy) 40.c. Place of Admission (City or Town and State) 41. Did you gain lawful permanent resident status through marriage to a U.S. citizen or lawful permanent resident? Yes/No Employment History [subheader] Provide your employment history for the last five years, whether inside or outside the United States. Provide your current employment first. If you are currently unemployed, type or print “Unemployed” in Item Number 42. Employer 1 42. Name of Employer/Company 43.a. Street Number and Name 43.b. Apt. Ste. Flr. 43.c. City or Town 43.d. State 43.e. ZIP Code 43.f. Province 43.g. Postal Code 43.h. Country 44. Your Occupation 45.a. Date From (mm/dd/yyyy) 45.b. Date To (mm/dd/yyyy) Employer 2 46. Name of Employer/Company 47.a. Street Number and Name 47.b. Apt. Ste. Flr. 47.c. City or Town 47.d. State 47.e. ZIP Code 47.f. Province 47.g. Postal Code 47.h. Country 48. Your Occupation 49.a. Date From (mm/dd/yyyy) 49.b. Date To (mm/dd/yyyy)
New		[Page 4] Part 3. Biographic Information NOTE: Provide the biographic information about you, the petitioner. 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 [Page 5] 6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Pages 1-2, C. Information about your relative	[Page 1] C. Information about your relative 10. Alien Registration Number 9. U.S. Social Security Number (If any) 1. Name (Family name in CAPS) (First) (Middle) 7. Other Names Used (including maiden name) 3. Place of Birth (Town or City) (State/Country) 4. Date of Birth 5. Gender Male Female 2. Address (Number and Street) (Apt. No.) (Town or City) (State/Country) (Zip/Postal Code) [Page 2] 18. Address in the United States where your relative intends to live. (Street Address) (Town or City) (State) 19. Your relative's address abroad. (Include street, city, province and country) Phone Number (if any) [Page 1] 6. Marital Status Married Single Widowed Divorced 8. Date and Place of Present Marriage (if married) 11. Name(s) of Prior Spouse(s) 12. Date(s) Marriage(s) Ended [Page 2] 17. List spouse and all children of your relative. (Name) (Relationship) (Date of Birth) (Country of Birth) (Name) (Relationship) (Date of Birth) (Country of Birth) (Name) (Relationship) (Date of Birth) (Country of Birth) (Name) (Relationship) (Date of Birth) (Country of Birth) (Name) (Relationship) (Date of Birth) (Country of Birth) [Page 1] 13. Has your relative ever been in the U.S.? 14. If your relative is currently in the U.S., complete the following: He or she arrived as a: (visitor, student, stowaway, without inspection, etc.) Arrival/Departure Record (I-94) Date arrived Date authorized stay expired, or will expire, as shown on Form I-94 or I-95 15. Name and address of present employer (if any) Date this employment began 16. Has your relative ever been under immigration proceedings? No Yes Removal Exclusion/Deportation Rescission Judicial Proceedings Where When [Page 2] 20. If your relative's native alphabet is other than Roman letters, write his or her name and foreign address in the native alphabet. (Name) Address (Include street, city, province and country) 21. If filing for your spouse, give last address at which you lived together. (Include street, city, province, if any, and country) From To 22. Complete the information below if your relative is in the United States and will apply for adjustment of status. Your relative is in the United States and will apply for adjustment of status to that of a lawful permanent resident at the USCIS office in: (City) (State) If your relative is not eligible for adjustment of status, he or she will apply for a visa abroad at the American consular post in: (City) (Country) NOTE: Designation of a U.S. embassy or consulate outside the country of your relative's last residence does not guarantee acceptance for processing by that post. Acceptance is at the discretion of the designated embassy or consulate.	[Page 5] Part 4. Information About Beneficiary 1. Alien Registration Number (A-Number) (if any) 2. USCIS Online Account Number (if any) 3. U.S. Social Security Number (if any) Beneficiary’s Full Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Other Names Used (if any) Provide all other names the beneficiary has ever used, including aliases, maiden name, and nicknames. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name Other Information About Beneficiary 6. City/Town/Village of Birth 7. Country of Birth [delete] [delete] 8. Date of Birth (mm/dd/yyyy) 9. Sex Male Female 10. Has anyone else ever filed a petition for the beneficiary? Y/N/Unknown NOTE: Select “Unknown” only if you do not know, and the beneficiary also does not know, if anyone else has ever filed a petition for the beneficiary. Beneficiary’s Physical Address If the beneficiary lives outside the United States in a home without a street number or name, leave Item Numbers 11.a. and 11.b. blank. 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. Province 11.g. Postal Code 11.h. Country Other Address and Contact Information Provide the address in the United States where the beneficiary intends to live, if different from Item Numbers 11.a. - 11.h. If the address is the same, type or print “SAME” in Item Number 12.a. 12.a. Street Number and Name 12.b. Apt. Ste. Flr. 12.c. City or Town 12.d. State 12.e. ZIP Code Provide the beneficiary’s address outside the United States, if different from Item Numbers 11.a. - 11.h. If the address is the same, type or print “SAME” in Item Number 13.a. 13.a. Street Number and Name 13.b. Apt. Ste. Flr. 13.c. City or Town 13.d. Province 13.e. Postal Code 13.f. Country 14. Daytime Telephone Number (if any) [Page 6] 15. Mobile Telephone Number (if any) 16. Email Address (if any) Beneficiary’s Marital Information 17. How many times has the beneficiary been married? 18. Current Marital Status Single, Never Married/Married/Divorced/ Widowed/Separated/Annulled 19. Date of Current Marriage (if currently married) (mm/dd/yyyy) Place of Beneficiary’s Current Marriage (if married) 20.a. City or Town 20.b. State 20.c. Province 20.d. Country Names of Beneficiary’s Spouses (if any) Provide information on the beneficiary’s current spouse (if currently married) first and then list all the beneficiary’s prior spouses (if any). Spouse 1 21.a. Family Name (Last Name) 21.b. Given Name (First Name) 21.c. Middle Name 22. Date Marriage Ended (mm/dd/yyyy) Spouse 2 23.a. Family Name (Last Name) 23.b. Given Name (First Name) 23.c. Middle Name 24. Date Marriage Ended (mm/dd/yyyy) Information About the Beneficiary’s Family [subheader] Provide information about the beneficiary’s spouse and children. Person 1 25.a. Family Name (Last Name) 25.b. Given Name (First Name) 25.c. Middle Name 26. Relationship 27. Date of Birth (mm/dd/yyyy) 28. Country of Birth Person 2 29.a. Family Name (Last Name) 29.b. Given Name (First Name) 29.c. Middle Name 30. Relationship 31. Date of Birth (mm/dd/yyyy) 32. Country of Birth Person 3 33.a. Family Name (Last Name) 33.b. Given Name (First Name) 33.c. Middle Name 34. Relationship 35. Date of Birth (mm/dd/yyyy) 36. Country of Birth [Page 7] Person 4 37.a. Family Name (Last Name) 37.b. Given Name (First Name) 37.c. Middle Name 38. Relationship 39. Date of Birth (mm/dd/yyyy) 40. Country of Birth Person 5 41.a. Family Name (Last Name) 41.b. Given Name (First Name) 41.c. Middle Name 42. Relationship 43. Date of Birth (mm/dd/yyyy) 44. Country of Birth Beneficiary’s Entry Information 45. Was the beneficiary EVER in the United States? Yes No If the beneficiary is currently in the United States, complete Item Numbers 46.a. - 46.d. 46.a. He or she arrived as a (Class of Admission): 46.b. Form I-94 Arrival-Departure Record Number 46.c. Date of Arrival (mm/dd/yyyy) 46.d. Date authorized stay expired, or will expire, as shown on Form I-94 or Form I-95 (mm/dd/yyyy) or type or print “D/S” for Duration of Status 47. Passport Number 48. Travel Document Number 49. Country of Issuance for Passport or Travel Document 50. Expiration Date for Passport or Travel Document (mm/dd/yyyy) Beneficiary’s Employment Information Provide the beneficiary’s current employment information (if applicable), even if they are employed outside of the United States. If the beneficiary is currently unemployed, type or print “Unemployed” in Item Number 51.a. 51.a. Name of Current Employer (if applicable) 51.b. Street Number and Name 51.c. Apt. Ste. Flr. 51.d. City or Town 51.e. State 51.f. ZIP Code 51.g. Province 51.h. Postal Code 51.i. Country 52. Date Employment Began (mm/dd/yyyy) Additional Information About Beneficiary [subheader] 53. Was the beneficiary EVER in immigration proceedings? Yes No 54. If you answered "Yes," select the type of proceedings and provide the location and date of the proceedings. Removal Exclusion/Deportation Rescission Other Judicial Proceedings 55.a. City or Town 55.b. State 56. Date (mm/dd/yyyy) [Page 8] If the beneficiary’s native written language does not use Roman letters, type or print his or her name and foreign address in their native written language. 57.a. Family Name (Last Name) 57.b. Given Name (First Name) 57.c. Middle Name 58.a. Street Number and Name 58.b. Apt. Ste. Flr. 58.c. City or Town 58.d. Province 58.e. Postal Code 58.f. Country If filing for your spouse, provide the last address at which you physically lived together. If you never lived together, type or print, "Never lived together" in Item Number 59.a. 59.a. Street Number and Name 59.b. Apt. Ste. Flr. 59.c. City or Town 59.d. State 59.e. ZIP Code 59.f. Province 59.g. Postal Code 59.h. Country 60.a. Date From (mm/dd/yyyy) 60.b. Date To (mm/dd/yyyy) [delete] The beneficiary is in the United States and will apply for adjustment of status to that of a lawful permanent resident at the U.S. Citizenship and Immigration Services (USCIS) office in: 61.a. City or Town 61.b. State The beneficiary will not apply for adjustment of status in the United States, but he or she will apply for an immigrant visa abroad at the U.S. Embassy or U.S. Consulate in: 62.a. City or Town 62.b. Province 62.c. Country NOTE: Choosing a U.S. Embassy or U.S. Consulate outside the country of the beneficiary’s last residence does not guarantee that it will accept the beneficiary’s case for processing. In these situations, the designated U.S. Embassy or U.S. Consulate has discretion over whether or not to accept the beneficiary case.
Page 2, D. Other information	[Page 2] D. Other Information 2. Have you ever before filed a petition for this or any other alien? Yes No If "Yes," give name, place and date of filing and result. 1. If separate petitions are also being submitted for other relatives, give names of each and relationship. WARNING: USCIS investigates claimed relationships and verifies the validity of documents. USCIS seeks criminal prosecutions when family relationships are falsified to obtain visas. PENALTIES: By law, you may be imprisoned for not more than five years or fined $250,000, or both, for entering into a marriage contract for the purpose of evading any provision of the immigration laws. In addition, you may be fined up to $10,000 and imprisoned for up to five years, or both, for knowingly and willfully falsifying or concealing a material fact or using any false document in submitting this petition.	[Page 8] Part 5. Other Information 1. Have you EVER previously filed a petition for this beneficiary or any other alien? Yes No If you answered "Yes," provide the name, place, date of filing, and the result. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3.a. City or Town 3.b. State 4. Date Filed (mm/dd/yyyy) 5. Result (for example, approved, denied, withdrawn) If you are also submitting separate petitions for other relatives, provide the names of and your relationship to each relative. Relative 1 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name 7. Relationship [Page 9] Relative 2 8.a. Family Name (Last Name) 8.b. Given Name (First Name) 8.c. Middle Name 9. Relationship WARNING: USCIS investigates the claimed relationships and verifies the validity of documents you submit. If you falsify a family relationship to obtain a visa, USCIS may seek to have you criminally prosecuted. PENALTIES: By law, you may be imprisoned for up to 5 years or fined $250,000, or both, for entering into a marriage contract in order to evade any U.S. immigration law. In addition, you may be fined up to $10,000 and imprisoned for up to 5 years, or both, for knowingly and willfully falsifying or concealing a material fact or using any false document in submitting this petition.
Page 2, D. Other information and E. Signature of petitioner	[E. Signature of petitioner] Phone Number( ) [D. Other Information] YOUR CERTIFICATION: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Furthermore, I authorize the release of any information from my records that U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit that I am seeking. Signature of petitioner Date	[Page 9] Part 6. Petitioner’s Statement, Contact Information, Declaration, and Signature NOTE: Read the Penalties section of the Form I-130 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 I have read and understand every question and instruction on this petition and my answer to every question. 1.b. [] The interpreter named in Part 7. read to me every question and instruction on this petition and my answer to every question in [Fillable Field], a language in which I am fluent. I understood all of this information as interpreted. 2. [] At my request, the preparer named in Part 8., [Fillable Field] prepared this petition for me based only upon information I provided or authorized. 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) Petitioner’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 of my records that USCIS may need to determine my eligibility for the immigration benefit I seek. I further 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 understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I provided or authorized all of the information contained in, and submitted with, my petition; 2) I reviewed and understood all of the information in, and submitted with, my petition; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my petition 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 petition, and that all of this information is complete, true, and correct. Petitioner’s Signature 6.a. Petitioner’s Signature 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.
New		[Page 10] Part 7. Interpreter’s Contact Information, Certification, and Signature Provide the following information about the interpreter if you used one. 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 Mobile Telephone Number (if any) 6. Interpreter’s Email Address (if any) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], which is the same language specified in Part 6., Item Number 1.b., and I have read to this petitioner in the identified language every question and instruction on this petition and his or her answer to every question. The petitioner informed me that he or she understands every instruction, question, and answer on the petition, including the Petitioner’s Declaration and Certification, and has verified the accuracy of every answer. [Page 11] Interpreter’s Signature 7.a. Interpreter's Signature 7.b. Date of Signature (mm/dd/yyyy)
Page 2, F. Signature of person preparing this form, if other than the petitioner	[Page 2] F. Signature of person preparing this form, if other than the petitioner [Address] I declare that I prepared this document at the request of the person above and that it is based on all information of which I have any knowledge. [Print Name] [Signature] [Date] G-28 ID or VOLAG Number, if any.	[Page 11] Part 8. Contact Information, Declaration, 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 Mobile Telephone 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 may be obliged to 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, under penalty of perjury, that I prepared this petition at the request of the petitioner. The petitioner then reviewed this completed petition and informed me that he or she understands all of the information contained in, and submitted with, his or her petition, including the Petitioner’s Declaration and Certification, and that all of this information is complete, true, and correct. I completed this petition based only on information that the petitioner provided to me or authorized me to obtain or use. [Deleted] Preparer’s Signature 8.a. Preparer's Signature 8.b. Date of Signature (mm/dd/yyyy) [Moved to beginning of form]
[New]		[Page 12] Part 9. 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. _______________________________ 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. Page Number 7.b. Part Number 7.c. Item Number 7.d. _______________________________

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