I-192 Form TOC

TABLE OF CHANGES – FORM

Form I-192, Application for Advance Permission to Enter as a Nonimmigrant

OMB Number: 1615-0017

5/7/2018

Reason for Revision: Revision and change to 2 column format.

Current Page Number and Section	Current Text	Proposed Text
Page 1, For DHS Use Only	[Page 1] FOR DHS USE ONLY Received Returned Trans.Out Fee Stamp Trans. In Completed Action by the Department of Homeland Security □ Granted, subject to revocation at any time, upon the following terms and conditions Date of Action (mm/dd/yyyy) DD or OIC Office	[Page 1] FOR DHS USE ONLY Received Returned Trans.Out Fee Stamp Trans. In Completed Action by the Department of Homeland Security Action Stamp Benefits Category: □ Nonimmigrant other than T or U nonimmigrant/Advance Permission under INA 212(d)(3)(A) and 8 CFR 212.4 □ T Nonimmigrant/Advance Permission under INA 212(d)(3) and 8 CFR 212.16 □ T Nonimmigrant /Waiver under INA 212(d)(13) and 8 CFR 212.16 □ U Nonimmigrant/Advance Permission under INA 212(d)(3)(A) and 8 CFR 212.17 □ U Nonimmigrant/Waiver under INA 212(d)(14) and 8 CFR 212.17 Ground of Inadmissibility □ INA 212(a)(1) □ INA 212(a)(2) □ INA 212(a)(3) □ INA 212(a)(4) □ INA 212(a)(6) □ INA 212(a)(8) □ INA 212(a)(9) □ INA 212(a)(10) □ Other: □ Granted, subject to revocation at any time, upon the following terms and conditions Date of Action (mm/dd/yyyy) DD or OIC Office
Page 1, To be completed by an attorney or BIA-accredited representative (if any).	[page 1] To be completed by an attorney or BIA-accredited representative (if any). Select this box if Form G-28 or Form G-28I is attached. Volag Number Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS ELIS Online Number (if any)	[page 1] To be completed by an attorney or accredited representative (if any). [no change] Volag Number (if any) [no change] Attorney or Accredited Representative USCIS Online Account Number (if any)
Page 1, Part 1. Application Type	[page 1] Part 1. Application Type I am applying to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of section 212(d)(3)(A)(ii), section 212(d)(13), or section 212(d)(14) of the Immigration and Nationality Act (INA). I am seeking this permission so that I may obtain (Select only one box): 1. A. Admission as a nonimmigrant (other than as a T or U nonimmigrant) B. Status as a victim of trafficking (T nonimmigrant status) or a victim of a crime (U nonimmigrant status)	[page 1] Part 1. Application Type I am applying to the Secretary of Homeland Security for permission to enter the United States temporarily under the provisions of the Immigration and Nationality Act (INA) section 212(d)(3)(A)(ii), section 212(d)(13), or section 212(d)(14). I am seeking this permission so that I may obtain (select only one box): 1. Admission as a nonimmigrant (other than as a T or U nonimmigrant). 2. Status as a victim of trafficking (T nonimmigrant status) or a victim of a crime (U nonimmigrant status).
Pages 1-4, Part 2. Information About You	[page 1] Part 2. Information About You [new] 1. Family Name (Last Name) Given Name (First Name) Middle Name [new] 2. Alien Registration Number (A-Number) (if any) 3. USCIS Online Account Number (if any) 4. Date of Birth (mm/dd/yyyy) [new] 5. Place of Birth City or Town State or Province Country 6. Country of Citizenship of Nationality [new] 7. Physical Address Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country [new] 8. Provide the addresses where you have resided during the past five years, starting with the last place you lived prior to your current physical address listed under Item Number 7. If you need extra space to complete this section, use the space provided in Part 7. Additional Information. A. Residence Number 1 Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country B. Residence Number 2 Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country C. Residence Number 3 Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country D. Residence Number 4 Date of Residence From (mm/dd/yyyy) To (mm/dd/yyyy) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Travel Information 9. Location at which you plan to enter the United States (desired Port-of-Entry) City State 10. Name of Port-of-Entry 11. How do you plan to travel to the United States? (For example, by plane, ship, car) 12. When do you plan to enter the United States? (mm/dd/yyyy) 13. Approximate Length of Stay in the United States 14. What is the purpose of your stay in the United States? Explain fully below. Immigration and Criminal History 15. Do you believe that you may be inadmissible to the United States? Yes No If you answered "Yes," explain the reasons why you believe, according to the best of your knowledge, that you may be inadmissible in Part 7. Additional Information. If you were told that you are inadmissible, provide the reason you were given. 16. Have you previously filed an application for advance permission to enter the United States as a nonimmigrant? Yes No If you answered “Yes,” provide the details in Items A. - C. in Item Number 17. If you need extra space to complete this section, use the space provided in Part 7. Additional Information. 17. A. Date Application Filed (mm/dd/yyyy) B. Location where you filed your application (For example, U.S. Citizenship and Immigration Services (USCIS) Office or Port-of-Entry) USCIS Office or U.S. Port-of-Entry City or Town State or Province Country C. Receipt Number (if available) NOTE: If you are an applicant for T nonimmigrant status or a petitioner for U nonimmigrant status, you do not need to answer Item Numbers 18. - 21. 18. Have you EVER been in the United States for a period of six months or more? Yes No If you answered “Yes,” provide the dates you were in the United States (from and to) and your immigration status at the time of entry into the United States in the space provided in Part 7. Additional Information. 19. Have you EVER filed an application or petition for immigration benefits with the U.S. Government, or has one ever been filed on your behalf? Yes No If you answered “Yes” to Item Number 19. provide the information in the space provided in Part 7. Additional Information. NOTE: If you (or somebody else on your behalf) have filed multiple applications or petitions for immigration benefits with the U.S. Government, use the space provided in Part 7. to also provide the following information: A. Type of Application or petition filed; B. Location where you (or the other person) filed the application or petition (for example, USCIS office or Port-of-Entry); C. Outcome of the application or petition (for example, approved, denied, or is pending) 20. Have you EVER been denied or refused an immigration benefit by the U.S. Government, or had a benefit revoked or terminated (including but not limited to visas)? Yes No If you answered “Yes” to Item Number 20., provide the information in the space provided in Part 7. Additional Information. 21. Have you EVER, in or outside the United States, been arrested, cited, charged, indicted, fined, convicted, or imprisoned for breaking or violating any law or ordinance, excluding minor traffic violations? If you answered “Yes,” describe the incidents in detail and include all offenses where impaired driving may have been an issue in the space provided in Part 7. Additional Information. Yes No	[page 1] Part 2. Information About You Your Full Name 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name Other Names Used (if any) Provide 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 8. Additional Information. 2.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name [page 2] 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name Other Information 4. Alien Registration Number (A-Number) (if any) 5. USCIS Online Account Number (if any) 6. Date of Birth (mm/dd/yyyy) 7. Gender M/F Place of Birth 8.a. City or Town 8.b. State or Province 8.c. Country 9. Country of Citizenship or Nationality Mailing Address 10.a. In Care Of Name (if any) 10.b. Street Number and Name 10.c. Apt Ste Flr 10.d. City or Town 10.e. State 10.f. ZIP Code 10.g. Province 10.h. Postal Code 10.i. Country Safe Mailing Address If you are a T or U visa applicant, and do not want U.S. Citizenship and Immigration Services (USCIS) to send notices about this application to your home, you may provide a safe mailing address. 11.a. In Care Of Name (if any) 11.b. Organization name (if applicable) 11.c. Street Number and Name 11.d. Apt Ste Flr 11.e. City or Town 11.f. State 11.g. ZIP Code 11.h. Province 11.i. Postal Code 11.j. Country [deleted] Address History Provide physical addresses for everywhere you have lived during 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 8. Additional Information. Physical Address 1 (current address) 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 Dates of Residence 13.a. From (mm/dd/yyyy) 13.b. To (mm/dd/yyyy) [Present] [page 3] Physical Address 2 14.a. Street Number and Name 14.b. Apt Ste Flr 14.c. City or Town 14.d. State 14.e. ZIP Code 14.f. Province 14.g. Postal Code 14.h. Country Dates of Residence 15.a. From (mm/dd/yyyy) 15.b. To (mm/dd/yyyy) _____________________________________ Physical Address 3 16.a. Street Number and Name 16.b. Apt Ste Flr 16.c. City or Town 16.d. State 16.e. ZIP Code 16.f. Province 16.g. Postal Code 16.h. Country Dates of Residence 17.a. From (mm/dd/yyyy) 17.b. To (mm/dd/yyyy) Physical Address 4 18.a. Street Number and Name 18.b. Apt Ste Flr 18.c. City or Town 18.d. State 18.e. ZIP Code 18.f. Province 18.g. Postal Code 18.h. Country Dates of Residence 19.a. From (mm/dd/yyyy) 19.b. To (mm/dd/yyyy) Travel Information NOTE: If you are applying for T or U nonimmigrant status and are in the United States, you may skip Item Numbers 20. - 25. Location at Which you Plan to Enter the United States (desired Port-of-Entry) 20.a. City 20.b. State 21. Name of Port-of-Entry 22. How do you plan to travel to the United States? (For example, by plane, ship, car) 23. When do you plan to enter the United States (mm/dd/yyyy)? 24. Approximate Length of Stay in the United States 25. What is the purpose of your stay in the United States? Explain fully below. [page 4] Immigration and Criminal History 26. Do you believe that you may be inadmissible to the United States? Yes No If you answered "Yes" to Item Number 26., explain the reasons why you believe, according to the best of your knowledge, that you may be inadmissible in Part 8. Additional Information. If you were told that you are inadmissible, provide the reason you were given. 27. Have you previously filed an application for advance permission to enter the United States as a nonimmigrant? Yes No If you answered "Yes" to Item Number 27., provide the details in Item Numbers 28. - 29.e. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 28. Date Application Filed (mm/dd/yyyy) Location where you filed your application (for example, USCIS Office or Port-of-Entry). 29.a. USCIS Office or U.S. Port-of-Entry 29.b. City or Town 29.c. State or Province 29.d. Country 29.e. Receipt Number (if available) [delete] 30. Have you EVER been in the United States for a period of six months or more? Yes No If you answered "Yes" to Item Number 30., provide the dates you were in the United States (from and to) and your immigration status at the time of entry into the United States in the space provided in Part 8. Additional Information. 31. Have you EVER filed an application or petition for immigration benefits with the U.S. Government, or has one ever been filed on your behalf? Yes No If you answered “Yes” to Item Number 31., provide the information requested in Item Numbers 32.a. - 32.c. If you (or somebody else on your behalf) have filed multiple applications or petitions for immigration benefits with the U.S. Government, use the space provided in Part 8. Additional Information to provide the answers to Item Numbers 32.a. - 32.c. for each of your additional applications or petitions. 32.a. Type of Application or Petition Filed 32.b. Location Where You (or the Other Person) Filed the Application or Petition (for example, USCIS office or Port-of-Entry); 32.c. Outcome of the Application or Petition (for example, approved, denied, or is pending). 33. Have you EVER been denied or refused an immigration benefit by the U.S. Government, or had a benefit revoked or terminated (including but not limited to visas)? Yes No If you answered “Yes” to Item Number 33., provide an explanation in the space provided in Part 8. Additional Information. 34. Have you EVER, in or outside the United States, been arrested, cited, charged, indicted, fined, convicted, or imprisoned for breaking or violating any law or ordinance, excluding minor traffic violations? Yes No If you answered “Yes” to Item Number 34., describe the incidents in detail and include all offenses where impaired driving may have been an issue in the space provided in Part 8. Additional Information.
Page 4, Part 3. Biographic Information	[page 4] Part 3. Biographic Information 1. Ethnicity (Select only one box) Hispanic or Latino Not Hispanic or Latino 2. Race (Select all applicable boxes) White Asian Black or African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander 3. Height Feet Inches 4. Weight Pounds 5. Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6. Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other	[page 4] Part 3. Biographic Information [no change] 2.  Race (Select all applicable boxes) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White [no change] [page 5]
New	[new]	[page 5] Part 4. Other Information About You Employment History Provide your employment history for the last five years, whether inside or outside the United States. Provide the most recent employment first. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. Employer 1 (current or most recent) 1. Name of Employer or Company Address of Employer or Company 2.a. Street Number and Name 2.b. Apt Ste Flr 2.c. City or Town 2.d. State 2.e. ZIP Code 2.f. Province 2.g. Postal Code 2.h. Country 3. Your Occupation Dates of Employment 4.a. From (mm/dd/yyyy) 4.b. To (mm/dd/yyyy) Employer 2 5. Name of Employer or Company Address of Employer or Company 6.a. Street Number and Name 6.b. Apt Ste Flr 6.c. City or Town 6.d. State 6.e. ZIP Code 6.f. Province 6.g. Postal Code 6.h. Country 7. Your Occupation Dates of Employment 8.a. From (mm/dd/yyyy) 8.b. To (mm/dd/yyyy) Information About Your Parents Information About Your Mother Mother's Legal Name 9.a. Family Name (Last Name) 9.b. Given Name (First Name) 9.c. Middle Name Mother's Name at Birth (if different than above) 10.a. Family Name (Last Name) 10.b. Given Name (First Name) 10.c. Middle Name 11. Date of Birth 12. City or Town of Birth 13. Country of Birth [page 6] 14. Current City or Town of Residence (if living) 15. Current Country of Residence (if living) Information About Your Father Father's Legal Name 16.a. Family Name (Last Name) 16.b. Given Name (First Name) 16.c. Middle Name Father's Name at Birth (if different than above) 17.a. Family Name (Last Name) 17.b. Given Name (First Name) 17.c. Middle Name 18. Date of Birth 19. City or Town of Birth 20. Country of Birth 21. Current City or Town of Residence (if living) 22. Current Country of Residence (if living) Information About Your Marital History 23. What is your current marital status? Single, Never Married Married Divorced Widowed Legally Separated Marriage Annulled Other 24. How many times have you been married (including annulled marriages and marriages to the same person)? Information About Your Current Marriage (including if you are legally separated) If you are currently married, provide the following information about your current spouse. Current Spouse's Legal Name 25.a. Family Name (Last Name) 25.b. Given Name (First Name) 25.c. Middle Name 26. A-Number (if any) 27. Current Spouse's Date of Birth (mm/dd/yyyy) 28. Date of Marriage to Current Spouse (mm/dd/yyyy) Current Spouse's Place of Birth 29.a. City or Town 29.b. State or Province 29.c. Country Place of Marriage to Current Spouse 30.a. City or Town 30.b. State or Province 30.c. Country [page 7] Information About Prior Marriages (if any) If you have been married before, whether in the United States or in any other country, provide the information requested in Item Numbers 31.a. - 36.c. about your prior marriage. If you have had more than one previous marriage, use the space provided in Part 8. Additional Information to provide the answers to Item Numbers 31.a. - 36.c. for each additional marriage. Prior Spouse's Legal Name (provide family name before marriage) 31.a. Family Name (Last Name) 31.b. Given Name (First Name) 31.c. Middle Name 32. Prior Spouse's Date of Birth (mm/dd/yyyy) 33. Date of Marriage to Prior Spouse (mm/dd/yyyy) Place of Marriage to Prior Spouse 34.a. City or Town 34.b. State or Province 34.c. Country 35. Date Marriage with Prior Spouse Legally Ended (mm/dd/yyyy) Place Where Marriage with Prior Spouse Legally Ended 36.a. City or Town 36.b. State or Province 36.c. Country
Page 5, Part 4. Applicant's Statement, Contact Information, Certification, and Signature	[page 5] Part 4. Applicant's Statement, Contact Information, Certification, and Signature NOTE: Read the information on penalties in the Penalties section of the Form I-192 Instructions before completing this part. [new] NOTE: Select the box for either Item A. or B. in Item Number 1.  If applicable, select the box for Item Number 2. 1. Applicant's Statement Regarding the Interpreter A. I can read and understand English, and have read and understand every question and instruction on this application and my answer to every question. B. The interpreter named in Part 5. read to me every question and instruction on this application, and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part 6., [Fillable Field], prepared this application for me based only upon information I provided or authorized. Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any) Applicant’s Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the immigration benefit I seek. I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws. I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and provided or authorized all of the information in my application; 2) I understood all of the information contained in, and submitted with, my application; and 3) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct. Applicant's Signature 6. Applicant's Signature Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application.	[page 7] Part 5. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature NOTE: Read the Penalties section of the Form I-192 Instructions before completing this section. Applicant’s Statement NOTE: Select the box for either Item Number 1.a. or 1.b. If applicable, select the box for Item Number 2. [deleted] 1.a. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question. 1.b. The interpreter named in Part 6. read to me every question and instruction on this application and my answer to every question in [Fillable Field], a language in which I am fluent, and I understood everything. [deleted] 2. At my request, the preparer named in Part 7., [Fillable Filed], prepared this application for me based only upon information I provided or authorized. [no change] Applicant’s Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that the U.S. Department of Homeland Security (DHS) may require that I submit original documents to DHS at a later date. Furthermore, I authorize the release of any information from any and all of my records that DHS may need to determine my eligibility for the immigration benefit that I seek. I furthermore authorize release of information contained in this application, in supporting documents, and in my DHS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. [page 8] I understand that DHS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1) I reviewed and understood all of the information contained in, and submitted with, my application; and [deleted] 2) All of this information was complete, true, and correct at the time of filing. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. Applicant’s Signature 6.a. Applicant’s Signature 6.b. Date of Signature (mm/dd/yyyy) [no change]
Page 6, Part 5. Interpreter's Contact Information, Certification, and Signature	[page 6] Part 5. 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. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code 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 4., Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer. Interpreter's Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy)	[page 8] Part 6. Interpreter’s Contact Information, Certification, and Signature [no change] Interpreter’s Full Name 1.a. Interpreter’s Family Name (Last Name) 1.b. Interpreter’s Given Name (First Name) [no change] 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 [no change] I am fluent in English and [Fillable Field], which is the same language specified in Part 5., Item Number 1.b., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant’s 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 7, Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[page 7] Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant Provide the following information about the preparer. Preparer's Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) Preparer's Mailing Address 3. Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code Province Postal Code Country Preparer's Contact Information 4. Preparer's Daytime Telephone Number 5. Preparer's Mobile Number (if any) 6. Preparer's Email Address (if any) Preparer's Statement 7. A. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent. B. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States, with this application. Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer's Signature 8. Preparer's Signature Date of Signature (mm/dd/yyyy)	[page 9] Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant [no change] Preparer’s Full Name 1.a. Preparer’s Family Name (Last Name) 1.b. Preparer’s Given Name (First Name) [no change] 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 [no change] Preparer’s Statement 7.a. I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant’s consent. 7.b. I am an attorney or accredited representative and my representation of the applicant in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, 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 application. Preparer’s Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the Applicant’s Declaration and Certification, and that all of this information is complete, true, and correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use. Preparer’s Signature 8.a. Preparer’s Signature 8.b. Date of Signature (mm/dd/yyyy)
Page 8, Part 7. Additional Information	[page 9] Part 7.  Additional Information 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 every sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 1. Family Name (Last Name) Given Name (First Name) Middle Name 2. A-Number (if any) 3. A. Page Number B. Part Number C. Item Number D. 4. A. Page Number B. Part Number C. Item Number D. 5. A. Page Number B. Part Number C. Item Number D. 6. A. Page Number B. Part Number C. Item Number D.	[page 10] Part 8.  Additional Information 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. 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) 1.b. Given Name (First Name) 1.c. Middle Name [no change] 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]]

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