Form I-918 A I-918 A Petition for Qualifying Family Member of U-1 Recipient

Supplement A, Petition for Qualifying Family Member
of U-1 Recipient
Department of Homeland Security
U.S. Citizenship and Immigration Services

Remarks

For
USCIS
Use
Only

USCIS
Form I-918
OMB No. 1615-0104
Expires 01/31/2016

Action Block

Receipt

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Validity Dates (mm/dd/yyyy) Wait Listed
U.S.
/
/
/
Embassy From:
Consulate To:
/
/
/
Stamp Number

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

Date (mm/dd/yyyy)

Attorney State Bar Number
(if applicable)

Select this box if
Form G-28 is
attached.

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

► START HERE - Type or print in black or blue ink.

NOTE: The recipient of the U-1 nonimmigrant classification is referred to as the "principal." His or her family members are referred
to as "derivatives." The principal should complete Supplement A.

Part 1. Family Member's Relationship To You
(Principal)

Part 3. Information About Your Qualifying
Family Member (Derivative)

1.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

The family member that I am filing for is my:
Spouse
Parent
Child
Unmarried sibling under 18 years of age

1.c. Middle Name

Part 2. Information About You (Principal)
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Other Names Used (Include maiden name, nicknames, and
aliases, if applicable)

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

1.c. Middle Name

2.c. Middle Name

Other Information

NOTE: If you need extra space to complete this section, use the
space provided in Part 11. Additional Information.

2.

Date of Birth (mm/dd/yyyy)

3.

Alien Registration Number (A-Number) (if any)
► A-

4.

3.a. Street Number
and Name

USCIS Online Account Number (if any)
►

5.

Residence or Intended Residence in the United
States

3.b.

Status of your Form I-918

Apt.

Flr.

3.c. City or Town
Pending

Approved
3.d. State

Form I-918 Supplement A 01/15/13 N

Ste.

3.e. ZIP Code

Page 1 of 12

Part 3. Information About Your Qualifying
Family Member (The Derivative) (continued)

17.

Date of Issuance for Passport or Travel Document
(mm/dd/yyyy)

Safe Mailing Address (if other than Residence)

18.

Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

4.a. In Care Of Name

Part 4. Additional Information About Your
Qualifying Family Member

4.b. Street Number
and Name
4.c.

Apt.

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Ste.

Provide the date of last entry, place of last entry, and current
immigration status for your family member if he or she is
currently in the United States.

Flr.

4.d. City or Town
4.e. State

4.f.

1.a. Date of Last Entry into the United States (mm/dd/yyyy)

ZIP Code

4.g. Province

Place of Last Entry into the United States

4.h. Postal Code

1.b. City or Town

4.i.

1.c. State

Country

1.d. Current Immigration Status

Other Information About Qualifying Family
Member
5.

A-Number (if any) ► A-

6.

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

7.

Provide the date of entry, place of entry, and status at entry
for your family member's last entry if he or she has
previously traveled to the United States but is not currently
in the United States.

2.a. Date of Last Entry into the United States (mm/dd/yyyy)

USCIS Online Account Number (if any)
►

Place of Last Entry into the United States

8.

Date of Birth (mm/dd/yyyy)

2.b. City or Town

9.

Country of Birth

2.c. State
2.d. Date Authorized Stay Expired (mm/dd/yyyy)

10.

Country of Citizenship or Nationality

11.

Marital Status

2.e. Status at the Time of Entry (for example, F-1 student,
B-2 tourist, entered without inspection)

Single

Married
Male

Divorced

12.

Gender

13.

Form I-94 Arrival-Departure Record Number

Widowed

Female

►
14.

Passport Number

15.

Travel Document Number

16.

Country of Issuance for Passport or Travel Document

Form I-918 Supplement A 01/15/13 N

Page 2 of 12

Part 4. Additional Information About Your
Qualifying Family Member (continued)
If your family member is outside the United States, provide
the U.S. Consulate or inspection facility or a safe foreign
mailing address you want notified if this supplement is
approved.
3.a. Type of Office (Select only one box):

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)
6.c. Middle Name
6.d. Date Marriage Ended (mm/dd/yyyy)
6.e. Where did the marriage end?

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U.S. Consulate

Pre-Flight Inspection

Port-of-Entry

6.f.

How did the marriage end?

3.b. City or Town
3.c. State
3.d. Country

Other Information

7.a. Your family member was or is in immigration
proceedings.
Yes

Safe Foreign Address Where You Want Notification Sent
(if other than U.S. Consulate, Pre-Flight Inspection, or
Port-of-Entry)
4.a. Street Number
and Name
4.b.

Apt.

Ste.

Flr.

4.c. City or Town
4.d. Province

If you answered "Yes," select the type of proceedings. If your
family member was in proceedings in the past and is no longer
in proceedings, provide the date of action. If your family
member is currently in proceedings, type or print “Current” in
the appropriate date field. Select all applicable boxes. Use the
space provided in Part 11. Additional Information to provide
an explanation.
7.b.

Country

Removal Proceedings

Removal Date (mm/dd/yyyy)

7.c.

Exclusion Proceedings

Exclusion Date (mm/dd/yyyy)

4.e. Postal Code
4.f.

No

7.d.

Deportation Proceedings

Deportation Date (mm/dd/yyyy)

7.e.
If your family member was previously married, list the
names of your family member's prior spouses and the dates
his or her marriages were terminated. You must attach
documents such as divorce decrees or death certificates.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
5.d. Date Marriage Ended (mm/dd/yyyy)
5.e. Where did the marriage end?

5.f.

7.f.

Rescission Proceedings
Rescission Date (mm/dd/yyyy)
Judicial Proceedings
Judicial Date (mm/dd/yyyy)

8.

Your family member would like an Employment
Authorization Document.
Yes

No

NOTE: If you answered "Yes," submit Form I-765,
Application for Employment Authorization Document,
separately. If your family member is living outside the
United States, he or she is not eligible to receive
employment authorization until he or she is lawfully
admitted to the United States. Do not file Form I-765 for
a family member living outside the United States.

How did the marriage end?

Form I-918 Supplement A 01/15/13 N

Page 3 of 12

Information About Arrests, Citations, Detentions, or Charges

Part 5. Processing Information
Answer the following questions about the family member for
whom you are filing this supplement. For the purposes of this
supplement, you must answer "Yes" to the following questions,
if applicable, even if your family member's records were sealed
or otherwise cleared or if anyone, including a judge, law
enforcement officer, or attorney, told your family member that
he or she no longer has a record.

2.a

Why was your family member arrested, cited, detained, or
charged?

2.b. Date of arrest, citation, detention, or charge (mm/dd/yyyy)

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NOTE: If you answer “Yes” to ANY question in Part 5.,
provide an explanation in the space provided in Part 11.
Additional Information.

Where was your family member arrested, cited, detained, or
charged?
2.c. City or Town

NOTE: Answering "Yes" does not necessarily mean that U.S.
Citizenship and Immigration Services (USCIS) will deny your
Supplement A, Petition for Qualifying Family Member of U-1
Recipient.
Has your family member EVER:

2.d. State

2.e. Country

2.f.

Outcome or disposition (for example, no charges filed,
charges dismissed, jail, probation)

3.a

Why was your family member arrested, cited, detained, or
charged?

1.a. Committed a crime or offense for which he or she has not
been arrested?
Yes
No
1.b. Been arrested, cited, or detained by any law enforcement
officer (including Department of Homeland Security
(DHS), former Immigration and Nationalization Service
(INS), and military officers) for any reason?
Yes

No

1.c. Been charged with committing any crime or offense?
Yes
No

1.d. Been convicted of a crime or offense (even if the violation
was subsequently expunged or pardoned)?
Yes

No

1.e. Been placed in an alternative sentencing or a rehabilitative
program (for example, diversion, deferred prosecution,
withheld adjudication, deferred adjudication)?
Yes
1.f.

Yes

Where was your family member arrested, cited, detained, or
charged?
3.c. City or Town
3.d. State

3.e. Country

No

Received a suspended sentence, been placed on probation,
or been paroled?
Yes
No

1.g. Been held in jail or prison?

3.b. Date of arrest, citation, detention, or charge (mm/dd/yyyy)

3.f.

Outcome or disposition (for example, no charges filed,
charges dismissed, jail, probation)

No

1.h. Been the beneficiary of a pardon, amnesty, rehabilitation,
or other act of clemency or similar action?
Yes
1.i.

No

Exercised diplomatic immunity to avoid prosecution for a
criminal offense in the United States?
Yes
No

Form I-918 Supplement A 01/15/13 N

Page 4 of 12

Part 5. Processing Information (continued)
Has your family member EVER:
4.a. Engaged in, or does he or she intend to engage in,
prostitution or procurement of prostitution?
Yes

No

4.b. Engaged in any unlawful commercialized vice, including,
but not limited to, illegal gambling?
Yes
No

Has your family member EVER been a member of, solicited
money or members for, provided support for, attended military
training (as defined in section 2339D(c)(1) of Title 18, United
States Code) by or on behalf of, or been associated with any other
group of two or more individuals, whether organized or not,
which has been designated as, or has engaged in or has a
subgroup which has been designated as, or has engaged in:
6.a. A terrorist organization under section 219 of the
Immigration and Nationality Act (INA)?

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4.c. Knowingly encouraged, induced, assisted, abetted, or
aided any alien to try to enter the United States illegally?
Yes

No

4.d. Illicitly trafficked in any controlled substance or knowingly
assisted, abetted, or colluded in the illicit trafficking of any
controlled substance?
Yes
No

Has your family member EVER committed, planned or prepared,
participated in, threatened to, attempted to, conspired to commit,
gathered information for, or solicited funds for any of the
following:
5.a. Hijacking or sabotage of any conveyance (including an
aircraft, vessel, or vehicle)?
Yes
No

5.b. Seizing or detaining, and threatening to kill, injure, or
continue to detain, another individual in order to compel a
third person (including a governmental organization) to
do or abstain from doing any act as an explicit or implicit
condition for the release of the individual seized or
detained?
Yes
No
5.c. Assassination?

Yes

No

5.d. The use of any firearm with intent to endanger, directly or
indirectly, the safety of one or more individuals or to
cause substantial damage to property?
Yes
No
5.e. The use of any biological agent, chemical agent, nuclear
weapon or device, explosive, or other weapon or
dangerous device, with intent to endanger, directly or
indirectly, the safety of one or more individuals or to
cause substantial damage to property?
Yes
No

Yes

No

6.b. Hijacking or sabotage of any conveyance (including an
aircraft, vessel, or vehicle)?
Yes
No
6.c. Seizing or detaining, and threatening to kill, injure, or
continue to detain, another individual in order to compel a
third person (including a governmental organization) to
do or abstain from doing any act as an explicit or implicit
condition for the release of the individual seized or
detained?
Yes
No

6.d. Assassination?

Yes

No

6.e. The use of any firearm with intent to endanger, directly or
indirectly, the safety of one or more individuals or to cause
substantial damage to property?
Yes
No

6.f.

The use of any biological agent, chemical agent, nuclear
weapon or device, explosive, or other weapon or dangerous
device, with intent to endanger, directly or indirectly, the
safety of one or more individuals or to cause substantial
damage to property?
Yes
No

6.g. Soliciting money or members or otherwise providing
material support to a terrorist organization?
Yes

No

Does your family member intend to engage in the United
States in:
7.a. Espionage?

Yes

No

7.b. Any unlawful activity, or any activity the purpose of
which is in opposition to, or the control, or overthrow of
the Government of the United States?
Yes
No
7.c. Solely, principally, or incidentally in any activity related
to espionage or sabotage or to violate any law involving
the export of goods, technology, or sensitive information?
Yes
8.

Form I-918 Supplement A 01/15/13 N

No

Has your family member EVER been or does he or she
continue to be a member of the Communist or other
totalitarian party, except when membership was
involuntary?
Yes
No

Page 5 of 12

Has your family member EVER:

Part 5. Processing Information (continued)
9.

Has your family member EVER, during the period of
March 23, 1933 to May 8, 1945, in association with either
the Nazi Government of Germany or any organization or
government associated or allied with the Nazi Government
of Germany, ordered, incited, assisted or otherwise
participated in the persecution of any person because of
race, religion, nationality, membership in a particular
social group or political opinion?
Yes
No

13.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or other insurgent organization?
Yes

No

13.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No

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Has your family member EVER ordered, incited, called for,
committed, assisted, helped with, or otherwise participated in any
of the following:

13.c. Served in, been a member of, assisted in, or participated
in any group, unit, or organization of any kind in which
you or other persons transported, possessed, or used any
type of weapon?
Yes
No

10.a. Acts involving torture or genocide?

Yes

No

10.b. Killing any person?

Yes

No

NOTE: If you answered "Yes" to any question in Item
Numbers 13.a. - 13.c., please describe the circumstances in
Part 11. Additional Information.

No

Has your family member EVER:

10.c. Intentionally and severely injuring any person?
Yes

10.d. Engaging in any kind of sexual conduct or relations with
any person who was being forced or threatened?
Yes

No

10.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes
No

10.f. The persecution of any person because of race, religion,
national origin, membership in a particular social group,
or political opinion?
Yes
No

10.g. Displacing or moving any person from their residence by
force, threat of force, compulsion, or duress?
Yes

No

NOTE: If you answered "Yes" to any question in Item
Numbers 10.a. - 10.g., please describe the circumstances in the
spaces provided in Part 11. Additional Information.

14.a. Received any type of military, paramilitary, or weapons
training?
Yes
No
14.b. Been a member of, assisted in, or participated in any
group, unit, or organization of any kind in which you or
other persons used any type of weapon against any person
or threatened to do so?
Yes
No

14.c. Assisted or participated in selling or providing weapons to
any person who to your knowledge used them against
another person, or in transporting weapons to any person
who to your knowledge used them against another
person?
Yes
No
NOTE: If you answered "Yes" to any question in Item
Numbers 14.a. - 14.c., please describe the circumstances in
Part 11. Additional Information.
Has your family member EVER:

11.

Has your family member EVER advocated that another
person commit any of the acts described in Item
Numbers 10.a. - 10.g., urged, or encouraged another
person, to commit such acts?
Yes
No

Has your family member EVER been present or nearby when
any person was:

15.a. Recruited, enlisted, conscripted, or used any person under
15 years of age to serve in or help an armed force or group?
Yes

No

15.b. Used any person under 15 years of age to take part in
hostilities, or to help or provide services to people in
combat?
Yes
No

12.a. Intentionally killed, tortured, beaten, or injured?
No

16.

12.b. Displaced or moved from his or her residence by force,
compulsion, or duress?
Yes
No

Is your family member NOW in removal, exclusion,
rescission, or deportation proceedings?
Yes
No

17.

Has your family member EVER had removal, exclusion,
rescission, or deportation proceedings initiated against
him or her?
Yes
No

Yes

12.c. In any way compelled or forced to engage in any kind of
sexual contact or relations?
Yes
No
Form I-918 Supplement A 01/15/13 N

Page 6 of 12

29.c. Is your family member NOW or has your family member
EVER been a drug abuser or drug addict?

Part 5. Processing Information (continued)
18.

Has your family member EVER been removed, excluded,
or deported from the United States?
Yes
No

19.

Has your family member EVER been ordered to be
removed, excluded, or deported from the United States?
Yes

No

Has your family member EVER been denied a visa or
denied admission to the United States? Yes
No

21.

Has your family member EVER been granted voluntary
departure by an immigration officer or an immigration
judge and failed to depart within the allotted time?
Yes

23.

No

Is your family member NOW under a final order or civil
penalty for violating section 274C of the INA (producing
and/or using false documentation to unlawfully satisfy a
requirement of the INA)?
Yes
No

Has your family member EVER, by fraud or willful
misrepresentation of a material fact, sought to procure or
procured a visa or other documentation, for entry into the
United States or any immigration benefit?
Yes

No

24.

Has your family member EVER left the United States to
avoid being drafted into the U.S. Armed Forces or U.S.
Coast Guard?
Yes
No

25.

Has your family member EVER been a J nonimmigrant
exchange visitor who was subject to the 2-year foreign
residence requirement and not yet complied with that
requirement or obtained a waiver of such?

26.

No

Part 6. Information About Your Qualifying
Family Member's Spouse and/or Children
Provide the following information about your family member's
spouse and/or children. If you need extra space to complete this
section, use the space provided in Part 11. Additional
Information.

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20.

22.

Yes

Yes
No
Has your family member EVER detained, retained, or
withheld the custody of a child, having a lawful claim to
United States citizenship, outside the United States from a
United States citizen granted custody?
Yes
No

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.

Date of Birth (mm/dd/yyyy)

3.

Country of Birth

4.

Relationship

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

5.c. Middle Name
6.

Date of Birth (mm/dd/yyyy)

7.

Country of Birth

8.

Relationship

27.

Does your family member plan to practice polygamy in
the United States?
Yes
No

9.a. Family Name
(Last Name)
9.b. Given Name
(First Name)

28.

Has your family member EVER entered the United States
as a stowaway?
Yes
No

9.c. Middle Name

29.a. Does your family member NOW have a communicable
disease of public health significance?
Yes
No
29.b. Does your family member NOW have or has your family
member EVER had a physical or mental disorder and
behavior (or a history of behavior that is likely to recur)
associated with the disorder which has posed or may pose
a threat to the property, safety, or welfare of yourself or
others?
Yes
No
Form I-918 Supplement A 01/15/13 N

10.

Date of Birth (mm/dd/yyyy)

11.

Country of Birth

12.

Relationship

Page 7 of 12

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:

Part 7. Petitioner's Statement, Contact
Information, Declaration, and Signature
NOTE: Read the Penalties section of the Form I-918
Instructions before completing this part.

1) I provided or authorized all of the information
contained in, and submitted with, my supplement;
2) I reviewed and understood all of the information in,
and submitted with, my supplement; and
3) All of this information was complete, true, and
correct at the time of filing.

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.

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1.a.

I can read and understand English, and I have read and
understand every question and instruction on this
supplement and my answer to every question.

1.b.

The interpreter named in Part 9. read to me every
question and instruction on this supplement and my
answer to every question in

,

a language in which I am fluent, and I understood
everything.
2.

6.a. Petitioner's Signature

,

Petitioner's Contact Information

4.

Petitioner's Signature

At my request, the preparer named in Part 10.,

prepared this supplement for me based only upon
information I provided or authorized.

3.

I certify, under penalty of perjury, that all of the information in
my supplement 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
supplement, and that all of this information is complete, true,
and correct.

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

NOTE TO ALL PETITIONERS: If you do not completely
fill out this supplement or fail to submit required documents
listed in the Instructions, USCIS may deny your supplement.

Petitioner's Daytime Telephone Number

Petitioner's Mobile Telephone Number (if any)

Part 8. Qualifying Family Member's Statement,
Contact Information, Declaration, and Signature

NOTE: Read the Penalties section of the Form I-918
Instructions before completing this part.

5.

Petitioner's Email Address (if any)

Qualifying Family Member's Statement
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.

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
supplement and my answer to every question.

1.b.

The interpreter named in Part 9. read to me every
question and instruction on this supplement and my
answer to every question in

I further authorize release of information contained in this
supplement, 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.

,
a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer named in Part 10.,
,
prepared this supplement for me based only upon
information I provided or authorized.

Form I-918 Supplement A 01/15/13 N

Page 8 of 12

Part 8. Qualifying Family Member's Statement,
Contact Information, Declaration, and Signature
(continued)
Qualifying Family Member's Contact Information
3.

Qualifying Family Member's Daytime Telephone Number

4.

Qualifying Family Member's Mobile Telephone Number
(if any)

5.

Qualifying Family Member's Signature
6.a. Qualifying Family Member's Signature

6.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL QUALIFYING FAMILY MEMBERS: If
you do not completely fill out this supplement or fail to submit
required documents listed in the Instructions, USCIS may deny
your supplement.

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Qualifying Family Member's Email Address (if any)

Part 9. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Qualifying Family Member's Declaration and
Certification

Interpreter's Full Name

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

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.

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

I further authorize release of information contained in this
supplement, 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. Any
disclosure shall be in accordance with 8 U.S.C. section 1367
and 8 CFR 214.14(e).

Interpreter's Mailing Address

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 supplement;
2) I reviewed and understood all of the information in,
and submitted with, my supplement; 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 supplement 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
supplement, and that all of this information is complete, true,
and correct.

Form I-918 Supplement A 01/15/13 N

2.

Interpreter's Business or Organization Name (if any)

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

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)

Page 9 of 12

Part 9. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Certification

Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

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 Part 8. Item Number 1.b., and I have read to this
petitioner and qualifying family member in the identified
language(s) every question and instruction on this supplement
and the petitioner's and qualifying family member's answer to
every question. The petitioner and qualifying family member
informed me that they understand every instruction, question,
and answer on the supplement, including the Petitioner's
Declaration and Certification and the Qualifying Family
Member's Declaration and Certification, and have verified
the accuracy of every answer.

3.c. City or Town

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3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Preparer's Contact Information

4.

Preparer's Daytime Telephone Number

7.a. Interpreter's Signature

5.

Preparer's Mobile Telephone Number (if any)

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

6.

Preparer's Email Address (if any)

Interpreter's Signature

Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Petition, if
Other Than the Petitioner or Qualifying Family
Member

Preparer's Statement

7.a.

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

7.b.

I am an attorney or accredited representative and my
representation of the petitioner and qualifying family
member in this case
extends
does not extend
beyond the preparation of this supplement.

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)

Form I-918 Supplement A 01/15/13 N

NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this supplement, you may be obliged to
submit a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative,
with this supplement.

Page 10 of 12

Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Petition, if
Other Than the Petitioner or Qualifying Family
Member (continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this supplement at the request of the petitioner and
qualifying family member. The petitioner and qualifying family
member then reviewed this completed supplement and informed
me that they understand all of the information contained in, and
submitted with, this supplement, including the Petitioner's
Declaration and Certification, and the Qualifying Family
Member's Declaration and Certification, and that all of this
information is complete, true, and correct. I completed this
supplement based only on information that the petitioner and
qualifying family member provided to me or authorized me to
obtain or use.

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Preparer's Signature

8.a. Preparer's Signature

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

Form I-918 Supplement A 01/15/13 N

Page 11 of 12

5.a. Page Number

Part 11. Additional Information
If you need extra space to provide any additional information
within this supplement, 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 supplement 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.

5.b. Part Number

5.c. Item Number

5.d.

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Your Full Name (Principal)
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

3.c. Item Number

6.d.

3.d.

7.a. Page Number
4.a. Page Number

4.b. Part Number

4.c. Item Number
7.d.

4.d.

Form I-918 Supplement A 01/15/13 N

Page 12 of 12