Form I-817 Application for Family Unity Benefits

Application for Family Unity Benefits

USCIS
Form I-817

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0005
Expires 06/30/2015

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Action Block

Fee Stamp

For USCIS Use Only
Returned (mm/dd/yyyy)

Resubmitted (mm/dd/yyyy)

Received (mm/dd/yyyy)
Relocated
Sent (mm/dd/yyyy)

Initial Application

Valid

Approved

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

From
To

Denied

/

/

Request for Extension

/

/

Select this box if
Form G-28 is
attached.

/

/

Approved

Valid

Remarks

From
To

Denied

/

/

/

/

/

/

Attorney State Bar Number
(if applicable)

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

► START HERE - Type or print in black ink.

NOTE: You must reside and file Form I-817 while in the
United States.

Part 1. Information About You (Person
Requesting Family Unity Benefits)
1.

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

Your Full Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name

Other Names Used
Provide any other names you have used since birth, including
maiden names, and nicknames.

Other Information

5.

Date of Birth (mm/dd/yyyy)

6.

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

7.

USCIS ELIS Account Number (if any)
►

8.

Gender

9.

Country of Birth

10.

Country of Citizenship or Nationality

Male

U.S. Mailing Address

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

11.a. In Care of Name

3.c.

11.b. Street Number
and Name

Middle Name

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c.

Middle Name

Form I-817 06/26/13 N

Female

11.c.

Apt.

Ste.

Flr.

11.d City or Town
11.e. State

11.f. ZIP Code

Page 1 of 12

On December 1, 1988, I was the spouse of an alien
who was legalized as a Special Agricultural Worker
under section 210 of the INA.

Part 1. Information About You (Person
Requesting Family Unity Benefits) (continued)

1.c.

U.S. Physical Address

1.d.

On December 1, 1988, I was the unmarried child
under 21 years of age of an alien who was a legalized
alien as a Special Agricultural Worker under section
210 of the INA.

1.e.

On May 5, 1988, I was the spouse of a legalized
alien who adjusted status under section 202 of the
Immigration Reform and Control Act of 1986
(Cuban/Haitian Adjustment).

1.f.

On May 5, 1988, I was the unmarried child under
21 years of age of a person who adjusted status
under section 202 of the Immigration Reform and
Control Act of 1986 (Cuban/Haitian Adjustment).

1.g.

I am the spouse of a person who is eligible for and
has filed or adjusted status under section 1104 of
Public Law (P.L.) 106-5534, the Legal Immigration
Family Equality (LIFE) Act. I entered the United
States on or before December 1, 1988, and resided
in the United States on that date.

1.h.

I am the unmarried child under 21 years of age of
a person who had filed an adjustment of status
application or adjusted status under section 1104
of P. L. 106-5534, the LIFE Act. I entered the
United States on or before December 1, 1988, and
resided in the United States on that date.

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12.a. Street Number
and Name
12.b.

Apt.

Ste.

Flr.

12.c. City or Town
12.d. State

12.e. ZIP Code

Biographic Information
13.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

14.

Race (Select all applicable boxes)
White
Asian
Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander
15.

Height

16.

Weight

17.

Eye Color (Select only one box)

18.

Feet

Inches

Blond
Red

NOTE: To be eligible for Immigration Act of 1990
(IMMACT 90) Family Unity Program benefits, your
qualifying spouse or parent must have maintained his or her
status as a legalized alien or as a U.S. citizen, if he or she
naturalized. If deceased, he or she must have maintained
status must have been maintained until his or her death. For
LIFE Act Family Unity, your spouse or parent must be eligible
for adjustment or have adjusted status under section 1104 of
the LIFE Act. If you previously qualified for LIFE Act
Family Unity, you may be eligible to apply for IMMACT 90
Family Unity Program Benefits.

Unknown/Other

I am requesting: (Select only one box)

Pounds

Black
Gray

Blue

Brown

Green

Hazel

Maroon

Pink

Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Black
Gray
White

2.a.

Initial Family Unity benefits under section 301 of
IMMACT 90.

2.b.

An extension of Family Unity benefits under section
301 of IMMACT 90.

2.c.

Initial Family Unity benefits under section 1504 of
the LIFE Act Amendments.

2.d.

An extension of Family Unity benefits under section
1504 of the LIFE Act Amendments.

Part 2. Basis For Application
I am applying for Family Unity benefits because: (Select
only one box)
1.a.

1.b.

On May 5, 1988, I was the spouse of an alien who
was legalized under section 245A of the Immigration
Nationality Act (INA).
On May 5, 1988, I was the unmarried child under 21
years of age of an alien who was legalized under
section 245A of the INA.

Form I-817 06/26/13 N

Page 2 of 12

Part 3. Information About Your Relationship

12.

Email Address (if any)

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If you need extra space to complete Part 3., use the space
provided in Part 9. Additional Information

Information About Your Spouse or Parent

Provide the following information about the legalized alien
through whom you are claiming your eligibility.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

Complete Only if You Are Applying Based on a
Marital Relationship or You Were Previously
Married

13. Marital Status
Married

Divorced

Widowed

Separated

Provide the following information about you and your spouse.
14.a. Number of times you have been married (including current
marriage)

1.c. Middle Name

Other Names Used (Including maiden name, nicknames, etc.)
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

14.b. Number of times your spouse has been married (including
spouse's current marriage)
If currently married, provide the following information about
your marriage.

2.c. Middle Name

15.a. Date of Marriage (mm/dd/yyyy)

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

Place of Marriage

15.b. City or Town

3.c. Middle Name

15.c. State

4.

Date of Birth (mm/dd/yyyy)

5.

A-Number (if any) ► A-

6.

USCIS ELIS Account Number (if any)

15.d. Province
15.e. Country

►

15.f. Type of Ceremony:

7.

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

8.

Gender

9.

Class of Admission (visitor, student, EWI, etc.)

Male

15.g. We are:
Female

Religious

Living together

Civil

None

Not living together

15.h. If you selected "Not living together," (select only one box):
My spouse has died
We are separated

We are divorced

Information About Your Prior Marriage
U.S. Physical Address for Your Spouse or Parent
10.a. Street Number
and Name
10.b.

Apt.

Ste.

Flr.

10.c. City or Town
10.d. State
11.

10.e. ZIP Code

Daytime Telephone Number (if any)

Form I-817 06/26/13 N

Provide the following information about your prior marriages
(if any).
16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)
16.c. Middle Name
17.a. Date of Marriage (if any) (mm/dd/yyyy)

Page 3 of 12

Part 3. Information About Your Relationship
(continued)

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Place of Prior Marriage
17.b. City or Town

17.c. State

19.d. Province
19.e. Country

19.f. Date of Termination (mm/dd/yyyy)
Place of Termination
19.g. City or Town

17.d. Province
17.e. Country

19.h. State

17.f. Date of Termination (mm/dd/yyyy)
Place of Termination
17.g. City or Town

17.h. State

19.i. Province

19.j. Country

19.k. Reason for Termination
Death
Divorce

Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 9. Additional Information.)

17.i. Province
17.j. Country

17.k. Reason for Termination
Divorce

Death

Annulment

Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 9. Additional Information.)

Information About Your Spouse's Prior Spouse
Provide the following information about your current spouse's
prior marriages (if any).
18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c. Middle Name
19.a. Date of Marriage (if any)
(mm/dd/yyyy)

NOTE: If you were previously married, you must complete
Part 3., Item Numbers 13. - 19.k. of this application; complete
all requested information about your prior marriages; and select
the box in Item Number 20. indicating that it is complete.
20.

I have completed Part 3., Item Numbers 13. - 19.k.,
information about my prior marriages (if any).

Complete Only if You Are Applying Based on a
Child/Parent Relationship
Indicate how your parent is related to you (Select only one box)
21.a.

Biological mother

21.b.

Biological father who was married to my mother
when I was born

21.c.

Biological father who was not married to my mother
when I was born

21.d.

Stepparent - based on marriage to my parent which
occurred before my 18th birthday

21.e.

Adoptive parent (select only one box):
A.

The adoption occurred before my 16th birthday.
Yes
No

B.

My adoptive parent had legal custody of me
on May 5, 1988 or December 1, 1988, (as
appropriate), and I resided with him or her for
two years prior to that date.

Place of Marriage
19.b. City or Town

19.c. State
Form I-817 06/26/13 N

Annulment

Yes

No
Page 4 of 12

Part 3. Information About Your Relationship
(continued)

Part 4. Other Information

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Provide the following information about your marital status.
22.a. Marital Status
Single, Never Married
Married
Widowed
Separated

Divorced

1.

Have you EVER applied before for the Family Unity
Program?
Yes
No
If you answered "Yes," provide the following information.

Name Under Which You Applied

23.a. Date of Marriage (mm/dd/yyyy)

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

Place of Marriage

2.c. Middle Name

23.b. City or Town

Place Where Application Was Filed

Provide the following information.

2.d. City or Town

23.c. State

2.e. State

23.d. Province

2.f.

23.e. Country

23.f. Type of ceremony:
23.g. We are:

Religious

Living together

Civil

None

Not living together

23.h. If you selected "Not living together," (Select only one box):
My spouse has died
We are divorced
We are separated
If divorced or widowed, provide the following information.
24.a. Date of Marriage (mm/dd/yyyy)
Place Marriage Ended
24.b. City or Town

24.c. State
24.d. Province
24.e. Country

Date Filed (mm/dd/yyyy)

2.g. U.S. Citizenship and Immigration Services (USCIS) (or
former Immigration and Naturalization Service (INS))
action taken on case
Approved
Denied

3.a. At the time of your last entry into the United States, you
(Select only one box):
Were inspected and admitted
Were inspected and paroled
Entered without inspection
3.b. Date of Last Arrival (mm/dd/yyyy)
3.c. Form I-94 Arrival-Departure Record Number
►
3.d. Passport Number
3.e. Travel Document Number
3.f.

Country of Issuance for Passport or Travel Document

3.g. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
3.h. Current or Most Recent Immigration Status

Form I-817 06/26/13 N

3.i.

Date Status Expires (mm/dd/yyyy)

3.j.

Date Continuous U.S. Residence Began (mm/dd/yyyy)

Page 5 of 12

Part 4. Other Information (continued)

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Provide the U.S. address where you lived on May 5, 1988 (INA
245Aor or Cuban Haitian Adjustment Act) or December 1,
1988 (INA section 210 or LIFE Act).
4.a. Street Number
and Name
4.b.

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

Apt.

8.c. Middle Name

8.d. A-Number (if any) ► A-

Ste.

Flr.

8.e. Relationship to Applicant

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

4.e. ZIP Code

If you are submitting separate applications for Family Unity
benefits are being submitted at this time for other relatives,
provide the following information about those other relatives.

NOTE: If you need more space to complete an answer in Item
Numbers 5.a. - 24.f., use Part 9. Additional Information.
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)

5.c. Middle Name

5.d. A-Number (if any) ► A5.e. Relationship to Applicant

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

9.c. Middle Name

9.d. A-Number (if any) ► A-

9.e. Relationship to Applicant

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

10.c. Middle Name

10.d. A-Number (if any) ► A-

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

10.e. Relationship to Applicant

6.d. A-Number (if any) ► A-

List all absences from the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Form I-817,
whichever date is later.

6.e. Relationship to Applicant

11.a. Departure Date (mm/dd/yyyy)

6.c. Middle Name

11.b. Return Date (mm/dd/yyyy)
7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)
7.c. Middle Name
7.d. A-Number (if any) ► A7.e. Relationship to Applicant

12.a. Departure Date (mm/dd/yyyy)
12.b. Return Date (mm/dd/yyyy)
13.a. Departure Date (mm/dd/yyyy)
13.b. Return Date (mm/dd/yyyy)
14.a. Departure Date (mm/dd/yyyy)
14.b. Return Date (mm/dd/yyyy)

Form I-817 06/26/13 N

Page 6 of 12

Part 4. Other Information (continued)

Previous Residence 2

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15.a. Departure Date (mm/dd/yyyy)

20.a. Street Number
and Name

15.b. Return Date (mm/dd/yyyy)

20.b.

20.d. State

16.b. Return Date (mm/dd/yyyy)

17.b. Return Date (mm/dd/yyyy)

Apt.

18.f. Dates of Residence (mm/dd/yyyy)
From
To

21.e. ZIP Code

To

Previous Residence 4

22.a. Street Number
and Name

Present

22.b.

Apt.

Ste.

Flr.

22.c. City or Town

Previous Residence 1

22.d. State

19.a. Street Number
and Name
Flr.

19.c. City or Town
19.d. State

Flr.

From

18.e. ZIP Code

Ste.

Ste.

21.f. Dates of Residence (mm/dd/yyyy)

Flr.

18.c. City or Town

Apt.

21.b.

21.d. State

18.a. Street Number
and Name

19.b.

21.a. Street Number
and Name

21.c. City or Town

Current Residence

18.d. State

20.e. ZIP Code

Previous Residence 3

List all residences in the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Family Unity
application (Form I-817), whichever date is later.

Ste.

Flr.

20.f. Dates of Residence (mm/dd/yyyy)
From
To

17.a. Departure Date (mm/dd/yyyy)

Apt.

Ste.

20.c. City or Town

16.a. Departure Date (mm/dd/yyyy)

18.b.

Apt.

19.e. ZIP Code

19.f. Dates of Residence (mm/dd/yyyy)
From
To

22.e. ZIP Code

22.f. Dates of Residence (mm/dd/yyyy)
From

To

Previous Residence 5
23.a. Street Number
and Name
23.b.

Apt.

Ste.

Flr.

23.c. City or Town
23.d. State

23.e. ZIP Code

23.f. Dates of Residence (mm/dd/yyyy)
From
To

Form I-817 06/26/13 N

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28.

Part 4. Other Information (continued)

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Previous Residence 6
24.a. Street Number
and Name
24.b.

Apt.

Ste.

29.

Flr.

24.c. City or Town
24.d. State

Have you EVER received any type of military,
paramilitary, or weapons training?
Yes

No

Have you EVER in the United States or Abroad:

24.e. ZIP Code

30.a. Engaged in, conspired to engage in, or intended to engage
in a terrorist activity with intent to cause death or serious
bodily harm?
Yes
No

24.f. Dates of Residence (mm/dd/yyyy)
From

Have you EVER 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

To

NOTE: If you need more space to complete an answer in Item
Numbers 5.a. - 24.f., use Part 9. Additional Information.

31.

Answer Item Numbers 25.a. - 38. If you answer “Yes” to
ANY of the questions, use the space provided in Part 9.
Additional Information to provide an explanation.

Have you EVER ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:

Have you EVER engaged in any activity to violate any
law of the United States related to espionage or sabotage
or to violate or evade any law prohibiting the export from
the United States of goods, technology, or sensitive
information?
Yes
No

Have you EVER:

25.a. Acts involving torture or genocide?

Yes

No

25.b. Killing any person?

Yes

No

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

30.b. Been a representative of a terrorist organization or a
member of an organization which you knew or should have
known is a terrorist organization?
Yes
No

No

32.a. Been convicted by a final judgment of a particularly
serious crime?
Yes
No

32.b. Participated in any other criminal activity which
endangers public safety or national security of the
United States?
Yes

No

33.

Have you EVER been convicted of any offenses for
which the aggregate sentences were five or more years
of confinement?
Yes
No

34.

Have you EVER been ordered deported, excluded, or
removed from the United States as you were inadmissible
at the time of entry or of adjustment of status, or violated
status?
Yes
No

26.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 insurgent organization?
Yes
No

35.

Have you EVER been convicted of a felony crime of
violence that has an element of or attempted use of
physical force against another individual in the course of
committing the offense?
Yes
No

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

36.

Have you EVER engaged in genocide, or ordered, incited,
assisted or otherwise participated in the persecution of
any person because of race, religion, national origin,
membership in a particular social group, or political
opinion?
Yes
No

25.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?
Yes
25.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes

No
No

Have you EVER:

27.

Have you EVER 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

Form I-817 06/26/13 N

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Applicant's Contact Information

Part 4. Other Information (continued)

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37.

Have you EVER committed a serious nonpolitical crime
outside the United States before you arrived in the United
States?
Yes
No

38.

Have you EVER been convicted of a felony or three or
more misdemeanors in the United States?
Yes

No

Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature

NOTE: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.

1.b.

The interpreter named in Part 6. has also read to me
every question and instruction on this application, as
well as my answer to every question, in
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.

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

I,
,
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.

Applicant's Statement

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.

Applicant's Daytime Telephone Number

Acknowledgement of Appointment at USCIS
Application Support Center

NOTE: Read the information on penalties in the Penalties
section of the Form I-817 Instructions before completing this
part.

1.a.

3.

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.

I have requested the services of and consented to
,
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.

Form I-817 06/26/13 N

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Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature (continued)

3.a. Street Number
and Name

Applicant's Certification

3.c. City or Town

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.

3.d. State

Interpreter's Mailing Address

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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 the information in my
application and any document submitted with my application
were provided by me and are complete, true, and correct.

Applicant's Signature

3.b.

3.f.

Apt.

Ste.

Flr.

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 Email Address (if any)

6.a. Applicant's Signature

Interpreter's Certification

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, your application may be denied.

Part 6. Interpreter's Contact Information,
Certification, and Signature
Provide the following information concerning 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)

I certify that:

I am fluent in English and
, 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
6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy)
Form I-817 06/26/13 N

Page 10 of 12

Part 7. Contact Information, Statement,
Certification, and Signature of the Person
Preparing This Application, If Other Than the
Applicant

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.

Provide the following information concerning the preparer.

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.

DRAFT
Not for
Reproduction
09/14/2015

Preparer's Full Name

1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
2.

Preparer's Statement

Preparer's Business or Organization Name (if any)

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

3.g. Postal Code

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.

3.h. Country

Preparer's Signature

Preparer's Mailing Address
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

8.a. Preparer's Signature

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

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

5.

Preparer's Fax Number (if any)

Part 8. Signature for Placement On Employment
Authorization Document

6.

Preparer's Email Address (if any)

Provide your signature below. This signature will be scanned
and duplicated for placement on your Employment
Authorization Document. When signing, make sure that no
part of your signature goes outside the lines of the box.
Signature

Form I-817 06/26/13 N

Page 11 of 12

5.a. Page Number

Part 9. Additional Information

5.b. Part Number

5.c. Item Number

DRAFT
Not for
Reproduction
09/14/2015

If you need extra space to provide any additional information
within this application, 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 application 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.d.

Your Full Name

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

1.c. Middle Name
2.

3.a. Page Number
3.d.

6.a. Page Number

A-Number (if any) ► A-

3.b. Part Number

3.c. Item Number

4.b. Part Number

4.c. Item Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

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

6.b. Part Number

7.d.

4.d.

Form I-817 06/26/13 N

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