TABLE OF CHANGES – FORM
Form I-526, Immigrant Petition by Alien Entrepreneur
OMB Number: 1615-0026
REV+FR 06262017 N
12/06/2016
Reason for Revision: Comprehensive revision to correlate with revision to Form I-924/I-924A; integration of standard language and formatting; incorporation of Fee Rule information.
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Current Page Number and Section |
Current Text |
Proposed Text |
Page 1,
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To be completed by Attorney or Representative, if any
G-28 is attached
Attorney's State License No.
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[Page 1] To be completed by attorney or BIA-accredited representative (if any).
__Select this box if Form G-28 is attached.
Attorney or Accredited Representative USCIS Online Account Number (if any)
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Page 1, Part 1, Information About You |
A-Number (if any)
Social Security Number (if any)
Family Name
Given Name
Middle Name
Address- In Care of Name, if applicable
Street Number and Name
Apt. Number
City
State or Province
Zip/Postal Code
Country
Date of Birth (mm/dd/yyyy)
Country of Birth
If you are in the United States, provide the following information:
Date of Arrival (mm/dd/yyyy)
I-94 Number
Passport Number
Travel Document Number
Country of Issuance for Passport or Travel Document
Expiration Date for Passport or Travel Document
Current Nonimmigrant Status
Date Current Status Expires (mm/dd/yyyy)
Daytime Telephone Number (with Area Code)
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[Page 1]
Part 1. Information About You
Provide the following information about yourself.
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
Other Names Used List all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
5.a. Family Name (Last Name) 5.b. Given
Name (First Name)
6.a. Family Name (Last Name) 6.b. Given
Name (First Name)
Mailing Address
7.a. In Care Of Name (if any)
7.b. Street Number and Name
7.c. Apt. Ste. Flr.
7.d. City or Town
7.e. State
7.f. ZIP Code
7.g. Province
7.h. Postal Code
7.i. Country
8. Is your current mailing address the same as your physical address? Yes No
If you answered “No” to Item Number 8., provide your physical address in Item Numbers 9.a.-9.h.
Physical Address
Provide your physical addresses for the last five years. Provide your present address first. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
9.a. Street Number and Name
9.b. Apt. Ste. Flr.
9.c. City or Town
9.d. State
9.e. ZIP Code
9.f. Province
9.g. Postal Code
9.h. Country
9.i. From (mm/dd/yyyy)
9.j. To ((mm/dd/yyyy) Present
10.a. Street Number and Name
10.b. Apt. Ste. Flr.
10.c. City or Town
10.d. State
10.e. ZIP Code
10.f. Province
10.g. Postal Code
10.h. Country
10.i. From (mm/dd/yyyy)
10.j. To (mm/dd/yyyy)
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
11.i. From (mm/dd/yyyy)
11.j. To (mm/dd/yyyy)
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
12.i. From (mm/dd/yyyy)
12.j. To (mm/dd/yyyy)
13.a. Street Number and Name
13.b. Apt. Ste. Flr.
13.c. City or Town
13.d. State
13.e. ZIP Code
13.f. Province
13.g. Postal Code
13.h. Country
13.i. From (mm/dd/yyyy)
13.j. To (mm/dd/yyyy)
Employment History
Provide your employment history for the last five years. (If none, so state.) List present employment first. If you need extra space to complete this section, use the space provided in Part 11. Additional Information.
14.a. Employer Name
14.b. Street Number and Name
14.c. Apt. Ste. Flr.
14.d. City or Town
14.e. State
14.f. ZIP Code
14.g. Province
14.h. Postal Code
14.i. Country
14.j. Job Title
14.k. From (mm/yyyy)
14.l. To (mm/yyyy) Present
15.a. Employer Name
15.b. Street Number and Name
15.c. Apt. Ste. Flr.
15.d. City or Town
15.e. State
15.f. ZIP Code
15.g. Province
15.h. Postal Code
15.i. Country
15.j. Job Title
15.k. From (mm/yyyy)
15.l. To (mm/yyyy)
16.a. Employer Name
16.b. Street Number and Name
16.c. Apt. Ste. Flr.
16.d. City or Town
16.e. State
16.f. ZIP Code
16.g. Province
16.h. Postal Code
16.i. Country
16.j. Job Title
16.k. From (mm/yyyy)
16.l. To (mm/yyyy)
17.a. Employer Name
17.b. Street Number and Name
17.c. Apt. Ste. Flr.
17.d. City or Town
17.e. State
17.f. ZIP Code
17.g. Province
17.h. Postal Code
17.i. Country
17.j. Job Title
17.k. From (mm/yyyy)
17.l. To (mm/yyyy)
18.a. Employer Name
18.b. Street Number and Name
18.c. Apt. Ste. Flr.
18.d. City or Town
18.e. State
18.f. ZIP Code
18.g. Province
18.h. Postal Code
18.i. Country
18.j. Job Title
18.k. From (mm/yyyy)
18.l. To (mm/yyyy)
Other Information About You 19. Date of Birth (mm/dd/yyyy)
20. Sex Male Female
Place of Birth
21. City or Town of Birth
22. State or Province of Birth
23. Country of Birth
24. Country of Citizenship or Nationality.
NOTE: If you are a citizen of more than one country or your nationality differs from your citizenship, provide the information in Part 11. Additional Information.
25. Country of Last Foreign Residence
Your Entry Into the United States
26. Date of Arrival (mm/dd/yyyy) Place of Arrival or Port-of-Entry 27.a. City or Town 27.b. State 28.a. I-94 Arrival-Departure Record Number 28.b. Date Period of Authorized Stay Expires/Expired (mm/dd/yyyy)
28.c. Passport Number
28.d. Travel Document Number
28.e. Country That Issued Passport or Travel Document
28.f. Date Passport or Travel Document Expires (mm/dd/yyyy)
28.g. Current Nonimmigrant Status (if applicable)
28.h. Date Current Nonimmigrant Status Expires (mm/dd/yyyy)
[Deleted; In signature section]
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Page 1, Part 2. Application Type (Check one)
Page 2, Part 4. Additional Information About the Enterprise |
Composition of the Petitioner’s Investment:
Total amount in U.S. bank account
Total value of all assets purchased for use in the enterprise
Total value of all property transferred from abroad to the new enterprise
Total of all debt financing
Total stock purchases
Other (explain on separate paper)
Total
Income:
When you made the investment
Gross
Net
Now
Gross
Net
Net Worth:
When you made the investment
Gross
Now
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[Page 4] Part 2. Information About Your Investment
Regional Center (if any)
Petition Type and Required Capital Investment
Select the appropriate box to indicate the type of petition you are filing. If you select Item Number 6., provide the requested information.
6. __Targeted Employment Area (TEA)
This petition is based on an investment in a targeted employment area for which the required investment amount of capital has been adjusted downward.
d. Address where the NCE is principally doing business
e. Is the job-creating-entity (JCE) principally doing business in a targeted employment area? Yes/No
f. Is the area a rural area? Yes/No
g. Is the area a high unemployment area? Yes/No
h. Address where the JCE is principally doing business
7. __Upward Adjustment Area
This petition is based on an investment in an area for which the required investment amount of capital has been adjusted upward.
8. __Non-TEA/Non-Upward Adjustment Area
This petition is based on an investment in an area that is neither a targeted employment area nor an upward adjustment area.
Composition of Your Investment and Your Income
Composition of Investment
Your Income
15. Your Gross Income at Time of Investment
16. Your Net Income at Time of Investment
17. Your Current Gross Income
18. Your Current Net Income
Your Net Worth
19. Your Net Worth at Time of Investment
20. Your Current Net Worth
Your Sources of Investment Capital
Please identify the source(s) of the capital you have invested or are actively in the process of investing into the NCE. (Select all that apply.)
21.a. Income 21.b. Indebtedness (Loan, Loan Proceeds, Promissory Note, etc.) 21.c. Gift (including capital obtained through inheritance) 21.d. Tangible Assets (Equipment, Inventory, etc.) 21.e. Other
21.f. In the space below, describe the documentation included with this petition to demonstrate that the capital you have invested or are actively in the process of investing was obtained through lawful means. ___________________________
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Page 1, Part 3. Information About Your Investment
Part 4. Additional Information About the Enterprise |
New commercial enterprise resulting from the creation of a new business.
New commercial enterprise resulting from the purchase of an existing business.
New commercial enterprise resulting from a capital investment in an existing business.
Name of commercial enterprise in which funds are invested (Required Field - Do Not Leave Blank)
Street Address
Phone Number with Area Code
Business organized as (corporation, partnership, etc.)
Kind of business (e.g. furniture manufacturer)
Date established (mm/dd/yyyy)
IRS Tax #
Date of your initial investment (mm/dd/yyyy)
Amount of your initial investment $___
Your total capital investment in the enterprise to date $_____
Percentage of the enterprise you own
If you are not the sole investor in the new commercial enterprise, list on separate paper the names of all other parties (natural and non- natural) who hold a percentage share of ownership of the new enterprise and indicate whether any of these parties is seeking classification as an alien entrepreneur. Include the name, percentage of ownership, and whether or not the person is seeking classification under section 203(b)(5). NOTE: A "natural" party would be an individual person, and a "non-natural" party would be an entity such as a corporation, consortium, investment group, partnership, etc.
If you indicated in Part 2 that the enterprise is in a targeted employment area or in an upward adjustment area, name the county and State:
County
State
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[Page 6]
Part 3. Information About the New Commercial Enterprise (NCE)
Type of NCE (Select only one)
1.a. NCE formed after November 29, 1990.
1.b. NCE resulting from the purchase of a business formed on or before November 29, 1990 that is restructured or reorganized
1.c. NCE resulting from a capital investment in and substantial expansion of a business formed on or before November 29, 1990.
Additional Information About the NCE
2. Name of NCE (Required Field - Do Not Leave Blank)
Address of NCE 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. County 3.e. State 3.f. ZIP Code
4. Telephone Number of NCE
5. Type of Entity (for example, corporation, limited liability company, partnership)
6. Nature of Activity (for example, furniture manufacturer)
7. Included Industries (provide North American Industry Classification System (NAICS) codes)
8. Have you invested or are you actively in the process of investing in a troubled business? Yes/No
NOTE: If you answered “Yes” to Item Number 8., you must provide an explanation in Part 11. Additional Information of how the NCE qualifies as a troubled business.
9. Date NCE Formed (mm/dd/yyyy)
10. Federal Employer Identification Number
11. Date of Your Initial Investment (mm/dd/yyyy)
12. Amount of Your Initial Investment in the NCE $___
13. Your Total Capital Investment in the NCE To Date $_____
14. What percentage of the NCE do you own? ___%
Multiple Investors. If you are not the sole investor in the NCE, list the name of any other person or entity (for example, a corporation, limited liability company, partnership, etc.) that holds a percentage ownership of the NCE. Also indicate the percentage of ownership and whether any of these persons obtained classification as an alien entrepreneur under INA section 203(b)(5) on the basis of his or her investment in this NCE or is seeking classification as an alien entrepreneur under INA section 203(b)(5). If you need additional space, provide the information in Part 11. Additional Information.
15.a. Name of Party 15.b. Percentage of Ownership 15.c. Is the party seeking classification as an alien entrepreneur under INA Section 203(b)(5) or has the party obtained classification as an alien entrepreneur under INA section 203(b)(5) on the basis of his or her investment in this NCE? Yes No
16.a. Name of Party 16.b. Percentage of Ownership 16.c. Is the party seeking classification as an alien entrepreneur under INA Section 203(b)(5) or has the party obtained classification as an alien entrepreneur under INA section 203(b)(5) on the basis of his or her investment in this NCE? Yes No
17.a. Name of Party 17.b. Percentage of Ownership 17.c. Is the party seeking classification as an alien entrepreneur under INA Section 203(b)(5) or has the party obtained classification as an alien entrepreneur under INA section 203(b)(5) on the basis of his or her investment in this NCE? Yes No
[Deleted] |
Page 2, Part 4. Additional Information About the Enterprise |
New commercial enterprise resulting from the creation of a new business.
New commercial enterprise resulting from the purchase of an existing business.
New commercial enterprise resulting from a capital investment in an existing business.
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[Page 7]
Part 4. Information About the Job-Creating Entity (JCE) (if different from the NCE)
3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. County 3.e. State 3.f. ZIP Code
4. Telephone Number of JCE (with area code)
5. Type of Entity (for example, corporation, limited liability company, partnership)
6. Nature of Activity (for example. furniture manufacturer)
7. Included Industries (provide North American Industry Classification System (NAICS) codes)
Multiple Job-Creating Entities. If there is more than one JCE involved in the project, provide information regarding all JCE’s involved with the new commercial enterprise. If you need additional space, use the space provided in Part 11. Additional Information.
8. Name of Additional Job-Creating Entity 9.a. Street Number and Name 9.b. Apt. Ste. Flr. 9.c. City or Town 9.d. County 9.e. State 9.f. ZIP Code
10. Telephone Number of Job-Creating Entity (with area code)
11. Type of Entity (for example, corporation, limited liability company, partnership)
12. Nature of Activity (for example, furniture manufacturer)
13. Included Industries (provide North American Industry Classification System (NAICS) codes)
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Page 3, Part 5. Employment Creation Information |
What is your position, office, or title with the new commercial enterprise?
Briefly describe your duties, activities, and responsibilities.
What is your salary?
What is the cost of your benefits?
Number of full-time employees in the enterprise in U.S. (excluding you, your spouse, sons, and daughters)
When you made your initial investment?
Now
Difference
How many of these new jobs were created by your investment?
How many additional new jobs will be created by your additional investment?
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[Page 8]
Part 5. Employment Creation Information
NOTE: If you need additional space, provide the information in Part 11. Additional Information.
If you answered “Yes” to Item Number 9, indicate the economic model used to estimate indirect job creation in Part 11. Additional Information.
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Page 3, Part 6. Processing Information |
Check One:
The person named in Part 1 is now in the United States, and an application to adjust status to permanent resident will be filed if this petition is approved.
The petition is approved and the person named in Part 1 wishes to apply for an immigrant visa abroad, complete the following for that person:
Country of current residence or, if now in the United States, last permanent residence abroad:
If you provided a United States address in Part 1, print the person's foreign address:
If the person's native alphabet is other than Roman letters, write the foreign address in the native alphabet:
Are you in deportation or removal proceedings?
Yes (Explain on separate paper)
No
Have you ever worked in the United States without permission?
Yes (Explain on separate paper) No
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[Page 8] Part 6. Processing Information
Select the appropriate box to indicate how you will seek lawful permanent resident status.
__1.a. Immigrant Visa Processing
1.b. Country of Citizenship or Nationality
1.c. Country of Current Residence
__2.a. Application for Adjustment of Status
2.b. Country of Last Permanent Residence Abroad
Address in Country of Last Permanent Residence Abroad
3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. Province 3.e. Postal Code 3.f. Country
4. Telephone Number
If your native alphabet is other than Roman letters, type or print the foreign address in your native alphabet, below.
5.a. Street Number and Name 5.b. Apt. Ste. Flr. 5.c. City or Town 5.d. Province 5.e. Postal Code 5.f. Country
Immigration Proceedings
Please indicate whether you are in exclusion, deportation, or removal proceedings before the Department of Homeland Security (DHS) or the Department of Justice’s (DOJ), Executive Office for Immigration Review (EOIR) Immigration Court or Board of Immigration Appeals. You also must provide an explanation for why are you in proceedings in Part 11. Additional Information.
6. Are you currently in immigration proceedings before the Department of Homeland Security (DHS) or Department of Justice (DOJ)? Yes No
Type of Proceedings (Select only one) 7.a. Exclusion 7.b. Deportation 7.c. Removal
Location of Proceedings 8.a. City or Town 8.b. State
9. Are you currently subject to a final order of exclusion, deportation, or removal, or subject to reinstatement of such an order? Yes/No
Employment in the United States
10. Have you ever worked in the United States without permission? Yes/No
11. If you answered “Yes” to Item Number 10., explain below. If you need additional space, use Part 11. Additional Information. |
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[Page 9] [New] Part 7. Information on Petitioner’s Spouse and Children
List your spouse and all of your children. Also, note if the individual will be applying for a visa abroad or for adjustment of status as your dependent. If you need additional space to list other children, use Part 11. Additional Information.
Family Member 1
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 to You 5. Applying for Adjustment of Status? Yes/No 6. Applying for Visa Abroad? Yes/No
Family Member 2
7.a. Family Name (Last Name) 7.b. Given Name (First Name) 7.c. Middle Name
8. Date of Birth (mm/dd/yyyy) 9. Country of Birth 10. Relationship to You 11. Applying for Adjustment of Status? Yes/No 12. Applying for Visa Abroad? Yes/No Family Member 3
13.a. Family Name (Last Name) 13.b. Given Name (First Name) 13.c. Middle Name
14. Date of Birth (mm/dd/yyyy) 15. Country of Birth 16. Relationship to You 17. Applying for Adjustment of Status? Yes/No 18. Applying for Visa Abroad? Yes/No
Family Member 4
19.a. Family Name (Last Name) 19.b. Given Name (First Name) 19.c. Middle Name
20. Date of Birth (mm/dd/yyyy) 21. Country of Birth 22. Relationship to You 23. Applying for Adjustment of Status? Yes/No 24. Applying for Visa Abroad? Yes/No Family Member 5
25.a. Family Name (Last Name) 25.b. Given Name (First Name) 25.c. Middle Name
26. Date of Birth (mm/dd/yyyy) 27. Country of Birth 28. Relationship to You 29. Applying for Adjustment of Status? Yes/No 30. Applying for Visa Abroad? Yes/No Family Member 6
31.a. Family Name (Last Name) 31.b. Given Name (First Name) 31.c. Middle Name
32. Date of Birth (mm/dd/yyyy) 33. Country of Birth 34. Relationship to You 35. Applying for Adjustment of Status? Yes/No 36. Applying for Visa Abroad? Yes/No
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Page 3, Part 7. Signature Read the information on penalties in the instructions before completing this section. |
Mobile Phone Number
E-Mail Address
Signature Date
NOTE: If you do not completely fill out this form or fail to the submit the required documents listed in the instructions, you may not be found eligible for the immigration benefit you are seeking and this petition may be denied. |
[Page 10]
Part 8. Statement, Contact Information, Declaration, Certification, and Signature of the Petitioner or Authorized Signatory
NOTE: Read the Penalties section of the Form I-526 Instructions before completing this part.
Petitioner’s or Authorized Signatory’s Statement
NOTE: Select the box for either Item 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 9. 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 10., [Fillable Filed], prepared this petition for me based only upon information I provided or authorized.
Authorized Signatory’s Contact Information 3.a. Authorized Signatory's Family Name (Last Name) 3.b.Authorized Signatory's Given Name (First Name) 4. Authorized Signatory's Title 5. Authorized Signatory's Daytime Telephone Number 6. Authorized Signatory's Mobile Telephone Number (if any) 7. Authorized Signatory's Email Address (if any)
Petitioner’s or Authorized Signatory’s Declaration and Certification
Copies of any documents submitted are exact photocopies of unaltered, original documents, and I understand that, as the petitioner, I may be required to submit original documents to USCIS at a later date.
I authorize the release of any information from my records, or from the petitioning organization’s records, to USCIS or other entities and persons where necessary to determine eligibility for the immigration benefit sought or where authorized by law. I recognize the authority of USCIS to conduct audits of this petition using publicly available open source information. I also recognize that any supporting evidence submitted in support of this petition may be verified by USCIS through any means determined appropriate by USCIS, including but not limited to, on-site compliance reviews.
If filing this petition on behalf of an organization, I certify that I am authorized to do so by the organization.
I certify, under penalty of perjury, that I have reviewed this petition, I understand all of the information contained in, and submitted with, my petition, and all of this information is complete, true, and correct.
Petitioner’s or Authorized Signatory’s Signature 8.a. Petitioner’s Signature 8.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL PETITIONERS OR AUTHORIZED SIGNATORIES: If you do not completely fill out this petition or fail to submit required documents listed in the Instructions, USCIS may delay a decision on or deny your petition. |
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[Page 11] [New] Part 9. Interpreter’s Contact Information, Certification, and Signature
Provide the following information about the interpreter.
Interpreter’s Full Name 1. Interpreter’s Family Name (Last Name) 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 specified in Part 8., Item 1.b., and I have read to this petitioner or the authorized signatory in the identified language every question and instruction on this petition and his or her answer to every question. The petitioner or authorized signatory informed me that he or she understands every instruction, question, and answer on the petition, including the Petitioner’s or Authorized Signatory’s Declaration and Certification, and has verified the accuracy of every answer.
Interpreter’s Signature 7.a. Interpreter’s Signature 7.b. Date of Signature (mm/dd/yyyy) |
Page 3, Part 8. Signature of Person Preparing Form, If Other Than Above (Sign below)
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Print Your Name
Firm Name
Address
Daytime phone # with area code
I declare that I prepared this application at the request of the above person, and it is based on all information of which I have knowledge.
Signature Date
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[Page 12]
Part 10. 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. [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 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, 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 or authorized signatory. The petitioner has reviewed this completed petition, including the Petitioner’s or Authorized Signatory’s Declaration and Certification, and informed me that all of this information in the form and in the supporting documents is complete, true, and correct.
Preparer’s Signature 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy) |
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[Page13] [New] Part 11. 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. _____________________________ |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | TABLE OF CHANGE – FORM I-687 |
| Author | jdimpera |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |