Form I-130A Supplemental Information for Spouse Beneficiary

Supplemental Information for Spouse Beneficiary
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-130A
OMB No. 1615-NEW
Expires xx/xx/20xx

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

Select this box if
Form G-28 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.

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The purpose of this form is to collect additional information for a spouse beneficiary of Form I-130, Petition for Alien Relative. If
your spouse is a U.S. citizen, lawful permanent resident, or non-citizen U.S. national who is filing Form I-130 on your behalf, you
must complete and sign Form I-130A, Supplemental Information for Spouse Beneficiary, and submit it with the Form I-130 filed by
your spouse. If you reside overseas, you still must complete Form I-130A, but you do not need to sign the form.

Part 1. Information About You (Spouse
Beneficiary)
1.

5.b. Date To (mm/dd/yyyy)

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

2.

5.a. Date From (mm/dd/yyyy)

USCIS Online Account Number (if any)
►

Physical Address 2

6.a. Street Number
and Name
6.b.

Apt.

Your Full Name

6.c. City or Town

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

6.d. State

3.c. Middle Name

6.g. Postal Code

6.f.

Ste.

Flr.

6.e. ZIP Code

Province

6.h. Country

Address History

Provide your physical addresses for the last five years, whether
inside or outside the United States. Provide your current
address first. If you need extra space to complete this section,
use the space provided in Part 7. Additional Information.

7.a. Date From (mm/dd/yyyy)
7.b. Date To (mm/dd/yyyy)

Physical Address 1

Last Physical Address Outside the United States

4.a. Street Number
and Name

Provide your last address outside the United States of more than
one year (even if listed above).

4.b.

Apt.

Ste.

Flr.

4.c. City or Town
4.d. State
4.f.

8.a. Street Number
and Name
8.b.

4.e. ZIP Code

Province

4.g. Postal Code
4.h. Country

Form I-130A xx/xx/xx N

Apt.

Ste.

Flr.

8.c. City or Town
8.d. Province
8.e. Postal Code
8.f.

Country

Page 1 of 6

Part 1. Information About You (The Spouse
Beneficiary)
9.a. Date From (mm/dd/yyyy)
9.b. Date To (mm/dd/yyyy)

Part 2. Information About Your Employment
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 1. below. If you
need extra space to complete this section, use the space
provided in Part 7. Additional Information.

Information About Your Mother
Your Mother's Full Name

Employment History

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10.a. Family Name
(Maiden Name)
10.b. Given Name
(First Name)

Employer 1

10.c. Middle Name

2.a. Street Number
and Name

11.

Date of Birth (mm/dd/yyyy)

2.b.

12.

City/Town/Village of Birth

2.c. City or Town

13.

Country of Birth

1.

City/Town/Village of Residence

15.

Country of Residence

Apt.

Ste.

Flr.

2.e. ZIP Code

2.d. State
2.f.

14.

Name of Employer/Company

Province

2.g. Postal Code
2.h. Country

3.

Your Occupation

Information About Your Father
Your Father's Full Name

4.a. Date From (mm/dd/yyyy)

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

4.b. Date To (mm/dd/yyyy)

Employer 2

16.c. Middle Name

5.

17.

Date of Birth (mm/dd/yyyy)

18.

City/Town/Village of Birth

19.

Country of Birth

Name of Employer/Company

6.a. Street Number
and Name
6.b.

Apt.

Ste.

Flr.

6.c. City or Town
20.

City/Town/Village of Residence

21.

Country of Residence

6.d. State
6.f.

6.e. ZIP Code

Province

6.g. Postal Code
6.h. Country

Form I-130A xx/xx/xx N

Page 2 of 6

Part 2. Information About Your Employment
(continued)

Part 4. Spouse Beneficiary's Statement, Contact
Information, Certification, and Signature

Employer 2 (continued)

NOTE: Read the information on penalties in the Penalties
section of the Form I-130A Instructions before completing
this part.

7.

Your Occupation

8.a. Date From (mm/dd/yyyy)

Spouse Beneficiary's Statement

8.b. Date To (mm/dd/yyyy)

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 have read and
understand every question and instruction on this
form, as well as my answer to every question.

1.b.

The interpreter named in Part 5. has read to me every
question and instruction on this form, as well as my
answer to every question, in

Part 3. Information About Your Employment
Outside the United States

Provide your last occupation outside the United States if not
shown above. If you never worked outside the United States,
provide this information in the space provided in Part 7.
Additional Information.
1.

a language in which I am fluent. I understand every
question and instruction on this form as translated to
me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.

Name of Employer/Company

2.a. Street Number
and Name
2.b.

Apt.

Ste.

Flr.

2.

2.c. City or Town
2.d. State
2.f.

Province

2.h. Country

3.

I have requested the services of and consented to
,

who
is
is not an attorney or accredited
representative, preparing this form for me.

2.e. ZIP Code

2.g. Postal Code

,

Spouse Beneficiary's Contact Information

3.

Spouse Beneficiary's Daytime Telephone Number

4.

Spouse Beneficiary's Mobile Telephone Number (if any)

5.

Spouse Beneficiary's Email Address (if any)

Your Occupation

4.a. Date From (mm/dd/yyyy)
4.b. Date To (mm/dd/yyyy)

Spouse Beneficiary'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 form, 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.

Form I-130A xx/xx/xx N

Page 3 of 6

Part 4. Spouse Beneficiary's Statement, Contact
Information, Certification, and Signature
(continued)
I certify under penalty of perjury, that the information in this
form, my responses to each question, and any document
submitted with this form were provided by me and are
complete, true, and correct.

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)

Spouse Beneficiary's Signature

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6.a. Spouse Beneficiary's Signature

Interpreter's Certification

I certify that:

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

NOTE TO ALL SPOUSE BENEFICIARIES: If you do not
completely fill out this form or fail to submit required documents
listed in the Instructions, USCIS may deny the Form I-130 filed
on your behalf.

Part 5. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter you used
to complete Form I-130A if he or she is different from the
interpreter used for completion of the Form I-130 filed on your
behalf.

I am fluent in English and
,
which is the same language provided in Part 4., Item Number
1.b.;
I have read to this spouse beneficiary every question and
instruction on this form, as well as the answer to every question,
in the language provided in Part 4., Item Number 1.b.; and
The spouse beneficiary has informed me that he or she
understands every instruction and question on the form, as well
as the answer to every question, and the spouse beneficiary
verified the accuracy of every answer.

Interpreter's Signature

7.a. Interpreter's Signature

Interpreter's Full Name

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

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

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

Part 6. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Petition, If Other Than the
Spouse Beneficiary

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.f.

Preparer's Full Name
1.a. Preparer's Family Name (Last Name)

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

Provide the following information about the preparer you used
to complete Form I-130A if he or she is different from the
preparer used to complete of the Form I-130 filed on your
behalf.

3.e. ZIP Code

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

Province

3.g. Postal Code

2.

Preparer's Business or Organization Name (if any)

3.h. Country

Form I-130A xx/xx/xx N

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Part 6. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Petition, If Other Than the
Spouse Beneficiary (continued)
Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.f.

Province

Preparer's Signature

3.e. ZIP Code

3.g. Postal Code
3.h. Country

By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this form on behalf of, at the request of,
and with the express consent of the spouse beneficiary. I
completed this form based only on responses the spouse
beneficiary provided to me. After completing the form, I
reviewed it and all of the spouse beneficiary's responses with
the spouse beneficiary, who agreed with every answer on the
form. If the spouse beneficiary supplied additional information
concerning a question on the form, I recorded it on the form.

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

Preparer's Certification

8.a. Preparer's Signature

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

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 form on behalf of the spouse
beneficiary and with the spouse beneficiary's consent.

7.b.

I am an attorney or accredited representative and my
representation of the spouse beneficiary in this case
extends
does not extend beyond the preparation
of this form.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this form, you must submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this form.

Form I-130A xx/xx/xx N

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5.a. Page Number

Part 7. 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 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.

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

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1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number 6.c. Item Number

6.d.

4.b. Part Number 4.c. Item Number

4.d.

Form I-130A xx/xx/xx N

7.a. Page Number

7.b. Part Number 7.c. Item Number

7.d.

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