Table of Changes (form)

TABLE OF CHANGES – FORM

Form I-140, Immigrant Petition for Alien Workers

OMB Number: 1615-0015

03/27/2018

Reason for Revision: Extension with standard language updates, including formatting, plain language, and consistency edits.

Legend for Proposed Text:

• Black font = Current text

• Purple font = Standard language

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
New		[Page 1] To be completed by an Attorney or Accredited Representative (if any). Select this box if Form G-28 or Form G-28I is attached. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)
Page 1, Part 1. Information About the Person or Organization Filing This Petition	[Page 1] START HERE – Type or print in black ink. Part 1. Information About the Person or Organization Filing This Petition (If an individual is filing, use numbers 1.a. - 1.c. If a Company or Organization is filing, use number 2). 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. Company or Organization Name Mailing Address 5.a. In Care of Name 5.b. Street Number and Name 5.c. Apt./Ste./Flr. [Fillable field] 5.d. City or Town 5.e. State 5.f. Zip Code 5.g. Postal Code 5.h. Province 5.i. Country Other Information 3. IRS Tax Number must be 9 digits; no dashes) 4. U.S. Social Security Number (if any) must be 9 digits; no dashes	[Page 1] [no change] Part 1. Information About the Person or Organization Filing This Petition If an individual is filing this petition, answer Item Numbers 1.a. - 1.c. If a company or organization is filing this petition, answer Item Number 2. 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 2. Company or Organization Name Mailing Address 3.a. In Care Of Name 3.b. Street Number and Name 3.c. Apt./Ste./Flr. [Fillable field] 3.d. City or Town 3.e. State 3.f. ZIP Code 3.g. Province 3.h. Postal Code 3.i. Country Other Information 4. IRS Employer Identification Number (EIN) 5. U.S. Social Security Number (SSN) (if any) 6. USCIS Online Account Number (if any)
Page 1, Part 2. Petition Type	[Page 1] Part 2. Petition Type This petition is being filed for: (Select only one box): 1.a. An alien of extraordinary ability. 1.b. An outstanding professor or researcher. 1.c. A multinational executive or manager. 1.d. A member of the professions holding an advanced degree or an alien of exceptional ability (who is NOT seeking a National Interest Waiver (NIW)). 1.e. A professional (at a minimum, possessing a bachelor's degree or a foreign degree equivalent to a U.S. bachelor's degree). 1.f. A skilled worker (requiring at least 2 years of specialized training or experience). 1.g. Any other worker (requiring less than 2 years of training or experience). 1.h. (Reserved) 1.i. An alien applying for a National Interest Waiver (who IS a member of the professions holding an advanced degree or an alien of exceptional ability). Check below if this petition is being filed: 2.a. To amend a previously filed petition. Previous Petition Receipt Number: 2.b. For the Schedule A, Group I or II designation.	[Page 1] Part 2. Petition Type This petition is being filed for (select only one box): 1.a. An alien of extraordinary ability. 1.b. An outstanding professor or researcher. 1.c. A multinational executive or manager. 1.d. A member of the professions holding an advanced degree or an alien of exceptional ability (who is NOT seeking a National Interest Waiver (NIW)). 1.e. A professional (at a minimum, possessing a bachelor's degree or a foreign degree equivalent to a U.S. bachelor's degree). 1.f. A skilled worker (requiring at least two years of specialized training or experience). 1.g. Any other worker (requiring less than two years of training or experience). [delete] 1.h. An alien applying for an NIW (who IS a member of the professions holding an advanced degree or an alien of exceptional ability). [Page 2] This petition is being filed (select only one box): 2.a. To amend a previously filed petition. Previous Petition Receipt Number: 2.b. For the Schedule A, Group I or II designation.
Page 2, Part 3. Information About the Person for Whom You Are Filing	[Page 2] Part 3. Information About the Person for Whom You Are Filing 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Mailing Address 2.a. In Care of Name 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Fillable field] 2.d. City or Town 2.e. State 2.f. Zip Code 2.g. Postal Code 2.h. Province 2.i. Country Other Information 3. E-mail Address (if any) 4. Daytime Phone Number 5. Date of Birth (mm/dd/yyyy) 6. City/Town/Village of Birth 7. State/Province of Birth 8. Country of Birth 9. Country of Citizenship 10. Country of Nationality 11. Alien Registration Number (A-Number) 12. U.S. Social Security Number (if any) must be 9 digits; no dashes If in the United States, please provide the following (complete all sections, as applicable): 13. Date of Arrival (mm/dd/yyyy) 14.a. I-94 Arrival-Departure Record Number: 16. Date Status Expires: (mm/dd/yyyy) 15. Current Nonimmigrant Status 14.b. Passport Number 14.c. Travel Document Number 14.d. Country of Issuance for Passport or Travel Document 14.e. Expiration Date for Passport or Travel Document (mm/dd/yyyy)	[Page 2] Part 3. Information About the Person for Whom You Are Filing 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Fillable field] 2.d. City or Town 2.e. State 2.f. ZIP Code 2.g. Province 2.h. Postal Code 2.i. Country Other Information [Delete] [Delete] 3. Date of Birth (mm/dd/yyyy) 4. City/Town/Village of Birth 5. State or Province of Birth 6. Country of Birth 7. Country of Citizenship or Nationality [Delete] 8. Alien Registration Number (A-Number) (if any) 9. U.S. SSN (if any) Information About His or Her Last Arrival in the United States If the person for whom you are filing is in the United States, provide the following information. 10. Date of Last Arrival (mm/dd/yyyy) 11.a. Form I-94 Arrival-Departure Record Number: 11.b. Expiration Date of Authorized Stay Shown on Form I-94 (mm/dd/yyyy) 11.c. Status on Form I-94 (for example, class of admission, or paroled, if paroled) 12. Passport Number 13. Travel Document Number 14. Country of Issuance for Passport or Travel Document 15. Expiration Date for Passport or Travel Document (mm/dd/yyyy)
Page 2-3, Part 4. Processing Information	[Page 2] Part 4. Processing Information Complete the following for the person named in Part 3: (Check one) 1.a. Alien will apply for a visa abroad at a U.S. Embassy or consulate at: City or Town Country 1.b. Alien is in the United States and will apply for adjustment of status to that of lawful permanent resident. Alien's country of current residence or, if now in the United States, last country of permanent residence abroad. [Fillable field] [Page 3] If you provided a United States address in Part 3, provide the person's foreign address: 2.a. Street Number and Name 2.b. Apt./Ste./Flr. [Fillable field] 2.c. City or Town 2.d. Postal Code 2.e. Province 2.f. Country If the person's native alphabet is other than Roman letters, write the person's foreign name and address in the native alphabet: 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Mailing Address 3.d. Street Number and Name 3.e. Apt./Ste./Flr. [Fillable field] 3.f. City or Town 3.g. Postal Code 3.h. Province 3.i. Country If you answered "Yes" to any of questions 4 through 8, provide the case number, office location, date of decision, and disposition of the decision on a separate sheet of paper. 4. Are any other petition(s) or application(s) being filed with this Form I-140? Yes No If you answered "Yes," check any applicable boxes: Form I-485 Form I-131 Form I-765 Other-Attach an explanation 5. Is the person for whom you are filing in removal proceedings? Yes - Attach an explanation No 6. Has any immigrant visa petition ever been filed by or on behalf of this person? Yes - Attach an explanation No 7. Is the petition being filed without an original labor certification because the original labor certification was previously submitted in support of another Form I-140? Yes - Attach an explanation No 8. If the petition is being filed without an original labor certification, are you requesting that USCIS request a duplicate labor certification from the Department of Labor? Yes - Attach an explanation No	[Page 2] Part 4. Processing Information Provide the following information for the person named in Part 3. (select only one box): 1.a. Alien will apply for a visa abroad at a U.S. Embassy or U.S. Consulate at: 1.b. City or Town 1.c. Country 2.a. Alien is in the United States and will apply for adjustment of status to that of lawful permanent resident. [Page 3] 2.b. Alien's current country of residence or, if now in the United States, last country of permanent residence abroad. [Fillable field] If you provided a United States address in Part 3., provide the person's foreign address in Item Numbers 3.a. - 3.f.: 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. Province 3.e. Postal Code 3.f. Country If the person's native alphabet is other than Roman letters, type or print the person's foreign name and address in the native alphabet in Item Numbers 4.a. - 4.c.: 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name Mailing Address 5.a. In Care Of Name 5.b. Street Number and Name 5.c. Apt./Ste./Flr. [Fillable field] 5.d. City or Town 5.e. Province 5.f. Postal Code 5.g. Country If you answer “Yes” to Item Numbers 6.a. - 10., provide the case number, office location, date of decision, and disposition of the decision in the space provided in Part 11. Additional Information. 6.a. Are you filing any other petitions or applications with this Form I-140? Yes No 6.b. If you answered “Yes” to Item Number 6.a., select all applicable boxes: Form I-485 Form I-131 Form I-765 Other (Provide an explanation in Part 11. Additional Information.) 7. Is the person for whom you are filing in removal proceedings? Yes No 8. Has any immigrant visa petition ever been filed by or on behalf of this person? Yes No 9. Are you filing this petition without an original labor certification because the original labor certification was previously submitted in support of another Form I-140? Yes No 10. If you are filing this petition without an original labor certification, are you requesting that U.S. Citizenship and Immigration Services (USCIS) request a duplicate labor certification from the Department of Labor (DOL)? Yes No
Page 3-4, Part 5. Additional Information About the Petitioner	[Page 3] Part 5. Additional Information About the Petitioner Type of petitioner (Select only one box): 1.a. Employer 1.b. Self 1.c. Other (Explain, e.g., Permanent Resident, U.S. citizen or any other person filing on behalf of the alien) If a company, give the following: 2.a. Type of Business 2.b. Date Established (mm/dd/yyyy) 2.c. Current Number of U.S. Employees 2.d. Gross Annual Income 2.e. Net Annual Income 2.f. NAICS Code 2.g. Labor Certification DOL/ETA Case Number [Page 4] 2.h. Labor Certification DOL/ETA Filing Date (mm/dd/yyyy) 2.i. Labor Certification Expiration Date (mm/dd/yyyy) If an individual, give following: 3.a. Occupation 3.b. Annual Income	[Page 3] Part 5. Additional Information About the Petitioner Type of petitioner (select only one box): 1.a. Employer 1.b. Self 1.c. Other (For example, Lawful Permanent Resident, U.S. citizen or any other person filing on behalf of the alien) If a company or an organization is filing this petition, provide the following information: 2. Type of Business 3. Date Established (mm/dd/yyyy) 4. Current Number of U.S. Employees 5. Gross Annual Income 6. Net Annual Income 7. NAICS Code 8. Labor Certification DOL Case Number [Page 4] 9. Labor Certification DOL Filing Date (mm/dd/yyyy) 10. Labor Certification Expiration Date (mm/dd/yyyy) If an individual is filing this petition, provide the following information. 11. Occupation 12. Annual Income
Page 4, Part 6. Basic Information About the Proposed Employment	[Page 4] Part 6. Basic Information About the Proposed Employment 1. Job Title 2. SOC Code 3. Nontechnical Description of Job 4. Is this a full-time position? Yes No 5. If the answer to Number 4 is "No," how many hours per week for the position? 6. Is this a permanent position? Yes No 7. Is this a new position? Yes No 8. Wages: $ [Fillable field] Per [Fillable field] (Specify hour, week, month, or year) Address where the person will work if different from address in Part 1. 9.a. Street Number and Name 9.b. Apt./Ste./Flr. [Fillable field] 9.c. City or Town 9.d. State 9.e. Zip Code	[Page 4] Part 6. Basic Information About the Proposed Employment 1. Job Title 2. SOC Code 3. Nontechnical Job Description 4. Is this a full-time position? Yes No 5. If the answer to Item Number 4. is "No," how many hours per week for the position? 6. Is this a permanent position? Yes No 7. Is this a new position? Yes No 8. Wages (Specify hour, week, month, or year): $ [Fillable field] Per [Fillable field] Worksite Location For Item Numbers 9.a. - 9.e., provide the address where the person will work if different from the address provided in Part 1. 9.a. Street Number and Name 9.b. Apt./Ste./Flr. [Fillable field] 9.c. City or Town 9.d. State 9.e. ZIP Code
Page 4-5, Part 7. Information on Spouse and All Children of the Person for Whom You Are Filing	[Page 4] Part 7. Information on Spouse and All Children of the Person for Whom You Are Filing List husband/wife and all children related to the individual for whom the petition is being filed. Also, note if the individual will be applying for a visa abroad or for adjustment of status as the dependent of the individual for whom the petition is filed. Provide an attachment of additional family members, if needed. Person 1 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name 1.d. Date of Birth (mm/dd/yyyy) 1.e. Country of Birth 1.f. Relationship 1.g. Applying for Adjustment of Status? Yes No 1.h. Applying for Visa Abroad? Yes No Person 2 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 2.d. Date of Birth (mm/dd/yyyy) 2.e. Country of Birth 2.f. Relationship 2.g. Applying for Adjustment of Status? Yes No 2.h. Applying for Visa Abroad? Yes No [Page 5] Person 3 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 3.d. Date of Birth (mm/dd/yyyy) 3.e. Country of Birth 3.f. Relationship 3.g. Applying for Adjustment of Status? Yes No 3.h. Applying for Visa Abroad? Yes No Person 4 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 4.d. Date of Birth (mm/dd/yyyy) 4.e. Country of Birth 4.f. Relationship 4.g. Applying for Adjustment of Status? Yes No 4.h. Applying for Visa Abroad? Yes No Person 5 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name 5.d. Date of Birth (mm/dd/yyyy) 5.e. Country of Birth 5.f. Relationship 5.g. Applying for Adjustment of Status? Yes No 5.h. Applying for Visa Abroad? Yes No Person 6 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name 6.d. Date of Birth (mm/dd/yyyy) 6.e. Country of Birth 6.f. Relationship 6.g. Applying for Adjustment of Status? Yes No 6.h. Applying for Visa Abroad? Yes No	[Page 4] Part 7. Information About the Spouse and All Children of the Person for Whom You Are Filing For Part 7., provide information on the spouse and all children related to the individual for whom you are filing this petition. Also, note if the individual will apply for a visa abroad or adjustment of status as the dependent of the individual for whom the petition is filed. If you need extra space to provide information about additional family members, use the space provided in Part 11. Additional Information. Person 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 5. Is he or she applying for adjustment of status? Yes No 6. Is he or she applying for a visa abroad? Yes No Person 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 11. Is he or she applying for adjustment of status? Yes No 12. Is he or she applying for a visa abroad? Yes No [Page 5] Person 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 17. Is he or she applying for adjustment of status? Yes No 18. Is he or she applying for a visa abroad? Yes No Person 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 23. Is he or she applying for adjustment of status? Yes No 24. Is he or she applying for a visa abroad? Yes No Person 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 29. Is he or she applying for adjustment of status? Yes No 30. Is he or she applying for a visa abroad? Yes No Person 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 35. Is he or she applying for adjustment of status? Yes No 36. Is he or she applying for a visa abroad? Yes No
Page 5, Part 8. Signature of Petitioner	[Page 5] Part 8. Signature of Petitioner 2. Daytime Phone Number 3. Mobile Phone Number 4. E-mail Address (if any) I certify, under penalty of perjury under the laws of the United States of America, that this petition and the evidence submitted with it are all true and correct. I authorize U.S. Citizenship and Immigration Services (USCIS) to release to other government agencies any information from my USCIS records, if USCIS determines that such action is necessary to determine eligibility for the benefit sought. 1.a. Signature of Petitioner 1.b. Date of Signature (mm/dd/yyyy) 5. Job Title of Position with Petitioning Employer, If the Petition Is Being Filed by an Employer NOTE: If you do not fully complete this form or fail to submit the required documents listed in the instructions, a final decision on your petition may be delayed or the petition may be denied.	[Page 6] Part 8. Statement, Contact Information, Declaration, Certification, and Signature of the Petitioner or Authorized Signatory NOTE: Read the Penalties section of the Form I-140 Instructions before completing this part. Petitioner’s or Authorized Signatory’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 petition and my answer to every question. 1.b. The interpreter named in Part 9. has 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) [delete] NOTE TO ALL PETITIONERS AND 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.
New		[Page 6] Part 9. 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) [Page 7] 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 Number 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 6, Part 9. Signature of Person Preparing This Petition, If Other Than the Petitioner	[Page 6] Part 9. Signature of Person Preparing This Petition, If Other Than the Petitioner 1. Attorney or Representative: In the event of a Request for Evidence (RFE), may USCIS contact you by e-mail? Yes No Provide the following information concerning the preparer: Preparer's Full Name 2.a. Preparer's Family Name (Last Name) 2.b. Preparer's Given Name (First Name) 3. Preparer's Business or Organization Name Preparer's Mailing Address 6.a. Street Number and Name 6.b. Apt./Ste./Flr. [Fillable field] 6.c. City or Town 6.d. State 6.e. Zip Code 6.f. Postal Code 6.g. Province 6.h. Country Preparer's Contact Information 4. Preparer's Daytime Phone Number Extension 5. Preparer's E-mail Address (if any) Declaration To be completed by all preparers, including attorneys and authorized representatives: I declare that I prepared this petition at the request of the petitioner, that it is based on all the information of which I have knowledge, and that the information is true to the best of my knowledge. 7.a. Signature of Preparer 7.b. Date of Signature (mm/dd/yyyy)	[Page 7] Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Petition, if Other Than the Petitioner [delete] 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 [delete] 5. Preparer’s Mobile Telephone Number (if any) 6. Preparer’s Email Address (if any) [Page 8] 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 need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or Form G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States, 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)
New		[Page 9] 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. IRS EIN [Auto-populated field] 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field] 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field] 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field] 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field] 7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]

1