Page 4,
Part
5. Applicant’s
Statement,
Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature
|
NOTE:
Read the information on penalties in the Penalties
section of the Form I-90 Instructions before completing this part.
Applicant’s
Statement
NOTE:
Select the box for either Item
Number 1.a.
or 1.b.
If applicable, select the box for Item
Number 2.
1.a.
[] I can read and understand English, and have read and
understand every question and instruction on this application, as
well as my answer to every question.
I have read and understand the Acknowledgement
of Appointment at USCIS Application
Support Center.
1.b.
[] The interpreter named in Part
6.
has read to me every question and instruction on this application,
as well as my answer to every question, in [Fillable Field], a
language in which I am fluent. I understand every question and
instruction on this application as translated to me by my
interpreter, and have provided complete, true, and correct
responses in the language indicated above. The interpreter named
in Part
6.
has also read the Acknowledgement
of Appointment at USCIS Application
Support Center
to me, in the language in which I am fluent, and I understand this
Application Support Center (ASC) Acknowledgement as read to me by
my interpreter.
2.
[] I have requested the services of and consented to [Fillable
Field], who [] is [] is not an attorney or accredited
representative, preparing this application for me. This person
who assisted me in preparing my application has reviewed the
Acknowledgement
of Appointment at USCIS Application
Support
Center
with me, and I understand the ASC Acknowledgement.
Applicant’s
Contact Information
3.
Applicant’s Daytime Telephone Number
4.
Applicant’s Mobile Telephone Number (if any)
5.
Applicant’s Email Address (if any)
Acknowledgement
of Appointment at USCIS Application
Support Center
I,
[Auto-populate Field with Applicant’s Full Name], understand
that the purpose of a USCIS ASC appointment is for me to provide
my fingerprints, photograph, and/or signature and to re-affirm
that all of the information in my application is complete, true,
and correct and was provided by me. I understand that I will sign
my name to the following declaration which USCIS will display to
me at the time I provide my fingerprints, photograph, and/or
signature during my ASC appointment.
By
signing here, I declare under penalty of perjury that I have
reviewed and understand my application, petition, or request as
identified by the receipt number displayed on the screen above,
and all supporting documents, applications, petitions, or requests
filed with my application, petition, or request that I (or my
attorney or accredited representative) filed with USCIS, and that
all of the information in these materials is complete, true, and
correct.
I
also understand that when I sign my name, provide my fingerprints,
and am photographed at the USCIS ASC, I will be re-affirming that
I willingly submit this application; I have reviewed the contents
of this application; all of the information in my application and
all supporting documents submitted with my application were
provided by me and are complete, true, and correct; and if I was
assisted in completing this application, the person assisting me
also reviewed this Acknowledgement
of Appointment at USCIS Application Support Center
with me.
Applicant’s
Certification
Copies
of any documents I have submitted are exact photocopies of
unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date.
Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my
eligibility for the immigration benefit that I seek.
I
furthermore authorize release of information contained in this
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 all of the information in
my application, my responses to each question, and any document
submitted with my application were provided by me and are
complete, true, and correct.
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.
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[Page
4]
Part
5. Applicant’s
Statement,
Contact Information, Certification, and Signature
NOTE:
Read the Penalties
section of the
Form
I-90 Instructions before completing
this part.
Applicant’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
application
and my
answer to every question.
1.b.
[]
The interpreter named in Part
6.
read to
me every
question and instruction on this application
and my
answer to every question
in [Fillable
Field], a language in which I am fluent
and I understood everything.
2.
[] At
my request, the preparer named in Part
7.,
[Fillable Filed], prepared this
application for me
based only upon information I provided or authorized.
Applicant’s
Contact Information
3.
Applicant’s Daytime
Telephone Number
4.
Applicant’s Mobile
Telephone Number (if any)
5.
Applicant’s Email
Address (if any)
[Deleted]
Applicant’s
Certification
Copies
of any documents I have submitted are exact photocopies of
unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date.
Furthermore, I authorize the release of any information from any
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 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
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 provided or authorized all of the information in my
application;
2)
I understood all of the information contained in, and submitted
with, my application; and
3)
All of this information was complete, true, and correct at the
time of filing.
I
certify,
under penalty
of perjury, that I
provided or authorized all
of the information in my application, I
understand all of the information contained in, and submitted
with, my application, and that all of this information is
complete, true, and correct.
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.
|
Page 5,
Part
6. Interpreter’s Contact Information,
Certification,
and Signature
|
Provide
the following information about the interpreter.
Interpreter’s
Full Name
1.a.
Interpreter's Family Name (Last Name)
1.b.
Interpreter's Given Name (First Name)
2.
Interpreter's Business or Organization Name (if any)
Interpreter’s
Mailing Address
3.a.
Street Number and Name
3.b.
[ ] Apt. [ ] Ste. [ ] Flr. [fillable field]
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 that:
I
am fluent in English and [Fillable Field], which is the same
language provided in Part
5.,
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
5.,
Item
Number 1.b.;
and
I
have read the Acknowledgement
of Appointment at USCIS Application Support Center
to the applicant in the same language provided in Part
5.,
Item
Number 1.b.
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; and
The
applicant has also informed me that he or she understands the ASC
Acknowledgement and that by appearing for a USCIS ASC biometric
services appointment and providing his or her fingerprints,
photograph, and/or signature, he or she is re-affirming that the
contents of this application and all supporting documentation are
complete, true, and correct.
Interpreter’s
Signature
7.a.
Interpreter's Signature
7.b.
Date of Signature (mm/dd/yyyy)
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[Page
5]
Part
6. Interpreter’s Contact Information,
Certification,
and Signature
Provide
the following information about the interpreter.
Interpreter’s
Full Name
1.a.
Interpreter’s Family Name (Last Name)
1.b.
Interpreter’s Given Name (First Name)
2.
Interpreter’s Business or Organization Name (if any)
Interpreter’s
Mailing Address
3.a.
Street Number and Name
3.b.
[ ] Apt. [ ] Ste. [ ] Flr. [fillable field]
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 provided in Part
5.,
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
Certification,
and has verified
the accuracy of every answer.
[Deleted]
Interpreter’s
Signature
7.a.
Interpreter’s Signature
7.b.
Date of Signature (mm/dd/yyyy)
|
Page 6,
Part
7. Contact Information, Statement, Certification, and Signature
of the Person Preparing this Application, If Other Than the
Applicant
|
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. [fillable field]
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 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, with this application.
Preparer’s
Certification
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. I have also read
the Acknowledgement
of Appointment at USCIS Application Support Center
to the applicant and the applicant has informed me that he or she
understands the ASC Acknowledgement.
Preparer’s
Signature
8.a.
Preparer's Signature
8.b.
Date of Signature (mm/dd/yyyy)
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[Page
6]
Part
7. Contact Information, Declaration,
and Signature of the Person Preparing this Application, if
Other
Than the Applicant
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. [fillable field]
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 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
may
be obliged to
submit a completed Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this application.
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
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
8.b.
Date of Signature (mm/dd/yyyy)
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