Form I-129CW Petition for CNMI-Only Nonimmigrant Transition Worker

Form I-129CW, Petition for a CNMI-Only
Nonimmigrant Transitional Worker

USCIS
Form I-129CW

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

OMB No. 1615-0111
Expires 05/31/2020

For USCIS Use Only
Partial Approval (explain)

Receipt

Action Block

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Classification Approved

Class:
# of Workers:
Job Code:
Priority Number:
Validity Dates: From:
To:

Consulate/POE/PFI Notified

At:

Extension Granted

COS/Extension Granted

► START HERE - Type or print in black ink.

Part 1. Information about the Employer Filing
This Petition

Part 2. Information About This Petition

NOTE: See the Instructions for fee information.

Name of Representative for Employer/Organization

1.

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

Basis for Classification (Select only one box):

1.c. Middle Name

Name of Employer/Organization and Address
2.a. Name of Employer/Organization

2.b. In Care Of Name (if any)

2.d.

Apt.

2.a.

New employment (including a duplicate for U.S.
Department of State notification).

2.b.

Continuation of previously approved employment
without change with the same employer.

2.c.

Change in previously approved employment.

2.d.

New concurrent employment.

2.e.

Change of employer.

2.f.

Amended petition.

3.

2.c. Street Number
and Name
Ste.

Requested Nonimmigrant Classification

If you selected Item Number 2.b., 2.c., 2.d., 2.e., or 2.f.,
provide the petition receipt number.
►

Flr.
4.

2.e. City or Town
2.f.

State

2.g. ZIP Code

3.

Federal Employer Identification Number

4.

USCIS Online Account Number (if any)

Prior Petition. If the beneficiary is in the CNMI as a
nonimmigrant and is applying to change and/or extend his
or her status, provide the prior petition or application
receipt number.

(USPS ZIP Code Lookup)

►

Form I-129CW 08/01/18

Page 1 of 15

Part 2. Information About This Petition
(continued)

3.

Date of Birth (mm/dd/yyyy)

4.

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

Requested Action (Select only one box):
5.a.

Notify the office in Part 4. so the beneficiary can
obtain a visa or be admitted.

5.b.

Change the beneficiary's status and extend their stay
since the beneficiary is in the CNMI in another status
(see the Instructions for limitations). This option is
available only where you select "New Employment"
in Item Number 2.a., above. Select the appropriate
box indicating the type of status change.

5.

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

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Initial Grant of CW-1 Status in CNMI

6.

Country of Birth

7.

Province of Birth

8.

Country of Citizenship or Nationality

Change of Federal Nonimmigrant Status to
CW-1

5.c.
5.d.

6.

Extend the stay of the beneficiary since they now
hold this status.

Amend the stay of the beneficiary since they now
hold this status.

Total number of workers in petition (See instructions
relating to when more than one worker can be included):

If in the CNMI, complete the following:
9.

Date of Last Arrival (mm/dd/yyyy)

10.

Form I-94 Arrival-Departure Record Number
►

11.a. Current Nonimmigrant Status

►

11.b. Date Status Expires (mm/dd/yyyy)

Part 3. Information About the Beneficiaries For
Whom You Are Filing

Provide the requested information below. If you need
additional space to complete this section, use the space provided
in Part 10. Additional Information. If you need additional
space to name each beneficiary included in this petition use
Form I-129CW Classification Supplement.

Beneficiary's Full Name
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name

12.a. Passport Number

12.b. Country Where Passport Was Issued

12.c. Date Passport Issued (mm/dd/yyyy)
12.d. Date Passport Expires (mm/dd/yyyy)

Beneficiary's Current CNMI Address
13.a. Street Number
and Name
13.b.

Apt.

Other Names Used (if any)

13.c. City or Town

Provide all other names the beneficiary has ever used, including
aliases, maiden name, and nicknames. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.

13.d. State

Ste.

Flr.

13.e. ZIP Code

2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)
2.c. Middle Name
Form I-129CW 08/01/18

Page 2 of 15

6.

Part 4. Processing Information
If the beneficiary named in Part 3. is outside the CNMI, or a
requested extension of stay, or change of status cannot be
granted, provide the U.S. Consulate or inspection facility you
want notified if this petition is approved.

Are applications by dependents being filed with this
petition?
►

Yes. If yes, how many?
No
7.

Is any beneficiary in this petition in removal proceedings?

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1.a. Type of Office (Select only one box):

Yes. If yes, explain in Part 10. Additional
Information.
No

Consulate

Pre-flight Inspection

8.

Port of Entry

1.b. Office Address (City)

Have you ever filed an immigrant petition for any
beneficiary in this petition?
Yes. If yes, explain in Part 10. Additional
Information.
No

1.c. U.S. State or Foreign Country

If you indicated you were filing a new petition in Part 2., has
any beneficiary in this petition:

Beneficiary's Foreign Address

9.

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

Apt.

Ste.

Yes. If yes, explain in Part 10. Additional
Information.
No

Flr.

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

Province

10.

2.e. ZIP Code

3.

Ever been denied the classification you are now
requesting?
Yes. If yes, explain in Part 10. Additional
Information.
No

2.g. Postal Code
2.h. Country

Ever been given the classification you are now
requesting?

11.

Have you ever previously filed a petition for this
beneficiary?
Yes. If yes, explain in Part 10. Additional
Information.
No

Does each beneficiary in this petition have a valid passport?
Yes

4.

No. If no, type or print a brief explanation in Part
10. Additional Information.

Part 5. Basic Information About the Proposed
Employment and Employer

Not Required to Have Passport

NOTE: Attach Form I-129CW Classification Supplement for
each beneficiary you are petitioning for.

Are you filing any other petitions with this one?
Yes. If yes, how many?

►

1.

Job Title

2.

SOC Code

3.

Nontechnical Job Description

No
5.

Are applications for replacement/initial Form I-94's being
filed with this petition?
Yes. If yes, how many?

►

-

►

No

Form I-129CW 08/01/18

Page 3 of 15

Part 5. Basic Information About the Proposed
Employment and Employer (continued)

Part 6. Information about the Beneficiary's
Public Benefits

Address where the beneficiary will work if different from
address in Part 1.

This Part 6. only applies to beneficiaries who are seeking to
change nonimmigrant status or extend their nonimmigrant stay
while they are in the CNMI. If the beneficiary is not seeking a
change of status or extension of stay, you may skip this Part 6.

4.a. Street Number
and Name
4.b.

Apt.

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Ste.

Provide the requested information and submit documentation as
outlined in the Instructions. For additional beneficiaries, please
respond to the questions in Part 2., Information about the
Additional Beneficiary's Public Benefits, in the Form
I-129CW Classification Supplement.

Flr.

4.c. City or Town
4.d. State
5.

4.e. ZIP Code

1.

Is this a full-time position?

Yes - Wages per week or per year:
$

Yes, the beneficiary has received or is currently
certified to receive the following benefits (select all
that apply):

No - Hours per week:
6.

Has the beneficiary, since obtaining the nonimmigrant
status that you seek to change on behalf of the
beneficiary, received, or is the beneficiary currently
certified to receive, any of the following public benefits?
(Select all that apply)

Other Compensation (Explain)

Any Federal, State, Local, or Tribal Cash
Assistance For Income Maintenance
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families
(TANF)

Dates of Intended Employment

General Assistance (GA)

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

Supplemental Nutrition Assistance Program
(SNAP, formerly called “Food Stamps”)

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

Section 8 Housing Assistance under the Housing
Choice Voucher Program

Type of Petitioner (Select only one box):
Business

9.

10.

Organization

Section 8 Project-Based Rental Assistance
(including Moderate Rehabilitation)

Other (Type or print a brief explanation in Part 10.
Additional Information.)

Public Housing under the Housing Act of 1937,
42 U.S.C. 1437 et seq.

Type of Business

Federally-funded Medicaid
No, the beneficiary has not received any of the above
listed public benefits.

Year Established

No, the beneficiary is not certified to receive any of
the above listed public benefits.
11.

Current Number of Employees

12.

Gross Annual Income

13.

Net Annual Income

Form I-129CW 08/01/18

2.

If the beneficiary has received or is currently certified to
receive any of the above public benefits, provide
information about the public benefits below. If you need
additional space to complete any Item Number in this
Part, use the space provided in Part 10. Additional
Information. Submit evidence as outlined in the
Instructions.

Page 4 of 15

D.

Part 6. Information about the Beneficiary's
Public Benefits (continued)
A.

Agency that Granted the Benefit

Type of Benefit

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)

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Agency that Granted the Benefit

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

B.

Type of Benefit

Agency that Granted the Benefit

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

C.

Type of Benefit

Type of Benefit

Agency that Granted the Benefit

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

Form I-129CW 08/01/18

Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

3.

If you answered “Yes” to Item Number 1., do any of the
following apply to the beneficiary? Provide the evidence
listed in the Form I-129CW Instructions.
The beneficiary is enlisted in the U.S. Armed Forces,
or is serving in active duty or in the Ready Reserve
Component of the U.S. Armed Forces.
The beneficiary is the spouse or the child of an
individual who is enlisted in the U.S. Armed Forces,
or who is serving in active duty or in the Ready
Reserve Component of the U.S. Armed Forces.
At the time the beneficiary received the public
benefits, the beneficiary (or the beneficiary's spouse
or parent) was enlisted in the U.S. Armed Forces, or
was serving in active duty or in the Ready Reserve
Component of the U.S. Armed Forces.
At the time the beneficiary received the public
benefits, the beneficiary was present in the United
States in a status exempt from the public charge
ground of inadmissibility and the beneficiary
received the public benefits during that time.
At the time the beneficiary received the public
benefits, the beneficiary was present in the United
States after being granted a waiver of the public
charge ground of inadmissibility.
The beneficiary is a child currently residing abroad
who entered the United States with a nonimmigrant
visa to attend an N-600K, Application for Citizenship
and Issuance of Certificate Under INA Section 322
interview.
None of the above statements apply to the
beneficiary.

Page 5 of 15

Petitioner's or Authorized Signatory's Contact
Information

Part 6. Information about the Beneficiary's
Public Benefits (continued)

3.a. Authorized Signatory's Family Name (Last Name)

4.a. Has the beneficiary received, applied for, or have been
certified to receive federally-funded Medicaid in
connection with any of the following (select all that
apply):

3.b. Authorized Signatory's Given Name (First Name)

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NOTE: Submit evidence as outlined in the Instructions.
An Emergency Medical Condition

For a Service Under the Individuals with Disabilities
Education Act (IDEA)
Other School-based Benefits or Services Available
Up to the Oldest Age Eligible for Secondary
Education Under State Law

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)

While Under 21 Years of Age

While Pregnant or During the 60-day Period
Following the Last Day of Pregnancy
4.b. Provide the Applicable Dates
Start Date (mm/dd/yyyy)

Petitioner's or Authorized Signatory's Declaration
and Certification

End Date (mm/dd/yyyy)

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.

Part 7. Statement, Contact Information,
Declaration, Certification, and Signature of the
Petitioner or Authorized Signatory

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.

NOTE: Read the Penalties section of the Form I-129CW
Instructions before completing this part. You, the petitioner,
must file Form I-129CW while in the United States.

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 8. has read to me every
question and instruction on this petition and my
answer to every question in
,
a language in which I am fluent. I understood all of
this information as interpreted.

2.

If filing this petition on behalf of an organization, I certify that I
am authorized to do so by the organization.
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 understood all of the information
contained in, and submitted with, my petition; and
2) All of this information was complete, true, and correct
at the time of filing.

At my request, the preparer named in Part 9.,
,
prepared this petition for me based only upon
information I provided or authorized.

Form I-129CW 08/01/18

Page 6 of 15

Part 7. Statement, Contact Information,
Declaration, Certification, and Signature of the
Petitioner or Authorized Signatory (continued)
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.

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

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6.

Interpreter's Email Address (if any)

Petitioner's or Authorized Signatory's Signature
8.a. Petitioner's Signature

Interpreter's Certification

I certify, under penalty of perjury, that:

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

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.

Part 8. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name

I am fluent in English and

,

which is the same language specified in Part 7., 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

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

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

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

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

Apt.

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

Ste.

Flr.

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

Provide the following information about the preparer.

Preparer's Full Name

3.a. Street Number
and Name
3.b.

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing This Petition,
if Other Than the Petitioner

1.b. Preparer's Given Name (First Name)
3.e. ZIP Code
2.

3.f.

Preparer's Business or Organization Name (if any)

Province

3.g. Postal Code
3.h. Country

Form I-129CW 08/01/18

Page 7 of 15

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing This Petition,
if Other Than the Petitioner (continued)
Preparer's Mailing Address

Apt.

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.

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3.a. Street Number
and Name
3.b.

Preparer's Certification

Ste.

Flr.

Preparer's Signature

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

Province

8.a. Preparer's Signature

3.e. ZIP Code

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

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 need to submit a completed
Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative, with this
petition.

Form I-129CW 08/01/18

Page 8 of 15

5.a. Page Number

Part 10. 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.

5.b. Part Number

5.c. Item Number

5.d.

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

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

4.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-129CW 08/01/18

4.c. Item Number

7.a. Page Number

7.d.

Page 9 of 15

Part 11. Accommodations for Individuals With
Disabilities and/or Impairments
NOTE: Read the information in the Form I-129CW
Instructions before completing this part.
1.

Name of Employer or Organization Filing Petition:

The beneficiary, if present in the CNMI, is lawfully present in
the CNMI.
The position is not temporary or seasonal employment, and the
above named petitioning employer does not reasonably believe
the position to qualify for any other nonimmigrant worker
classification.

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The position falls within the list of occupational categories
designated by the Secretary at 8 CFR 214.2(w)(1)(ix).

2.

Name of Person for Whom You Are Filing:

3.

Are you, the petitioning employer, requesting an
accommodation because of the beneficiary's disabilities
and/or impairments?

Select only one box:
1.a.

Professional, Technical, or Management Occupations

1.b.

Clerical and Sales Occupations

1.c.

Service Occupations

1.d.

If you answered “Yes” to Item Number 3., select any
applicable in Item Numbers 4.a. - 4.c. and provide an answer.

Agricultural, Fisheries, Forestry, and Related
Occupations

1.e.

Processing Occupations

4.a.

1.f.

Machine Trade Occupations

1.g.

Benchwork Occupations

1.h.

Structural Occupations

1.i.

Miscellaneous Occupations

Yes

No

The beneficiary is deaf or hard of hearing and
requests the following accommodation. (If they are
requesting a sign-language interpreter, indicate for
which language (for example, American Sign
Language).)

4.b.

The beneficiary is blind or has low vision and
requests the following accommodation:

4.c.

The beneficiary has another type of disability and/or
impairment. (Describe the nature of their disability
and/or impairment and the accommodation you are
requesting.)

I certify under penalty of perjury, under the laws of the United
States of America, that the contents of this attestation and the
evidence submitted with it are true and correct to the best of my
knowledge. If filing on behalf of an organization, I certify that I
am empowered to do so by the organization. If this petition is
to extend a prior petition, I certify that the proposed
employment is under the same terms and conditions as stated in
the prior approved petition. I authorize the release of any
information from my records, or from the petitioning
organization's record that U.S. Citizenship and Immigration
Services needs to determine eligibility for the benefit sought.
2.

Petitioner's Printed Name

3.

Title

4.

Employer/Organization Name

Part 12. Employer Attestation
Employer Attestation
There are no qualified U.S. workers available to fill the position
offered by the above named petitioning employer.
The above named petitioning employer is doing business as
defined in the regulations at 8 CFR 214.2(w)(1)(ii).
The above named petitioning employer is a legitimate business
as defined in the regulations at 8 CFR 214.2(w)(1)(vi).
The above named petitioning employer is an eligible employer
as described in 8 CFR 214.2(w)(4) and will continue to comply
with the requirements for an eligible employer until such time
as the employer no longer employs any CW-1 nonimmigrant
worker.
The beneficiary meets the qualifications for the position.

Form I-129CW 08/01/18

Page 10 of 15

Part 12. Employer Attestation (continued)
Employer/Organization's Physical Address
5.a. Street Number
and Name
5.b.

Apt.

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Flr.

5.c. City or Town
5.d. State

5.e. ZIP Code

Employer/Organization's Contact Information
6.

Daytime Telephone Number

7.

Fax Number (if any)

8.

Email Address (if any)

Petitioner's Signature
9.a. Petitioner's Signature

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

Form I-129CW 08/01/18

Page 11 of 15

Form I-129CW Classification Supplement
Department of Homeland Security
U.S. Citizenship and Immigration Services

Attach to Form I-129CW when more than one beneficiary is
included in the petition. (Provide each beneficiary separately.
Do not include the person you named on Form I-129CW.)

Part 1. Information About the Additional
Beneficiary (if applicable)

USCIS
Form I-129CW
OMB No. 1615-0111
Expires 05/31/2020

IF IN THE CNMI
9.

Date of Last Arrival (mm/dd/yyyy)

10.

Form I-94 Arrival-Departure Record Number
►

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11.a. Current Nonimmigrant Status

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

11.b. Date Status Expires (mm/dd/yyyy)

1.c. Middle Name

12.a. Passport Number

2.

Date of Birth (mm/dd/yyyy)

3.

U.S. Social Security Number (if any)

12.b. Country Where Passport Issued

►

4.

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

12.c. Date Passport Issued (mm/dd/yyyy)

12.d. Date Passport Expires (mm/dd/yyyy)

Beneficiary's Current CNMI Address
5.a. Street Number
and Name
5.b.

Apt.

Ste.

Flr.

Part 2. Information about the Additional
Beneficiary's Public Benefits

1.

5.c. City or Town
5.d. State

5.e. ZIP Code

Beneficiary's Foreign Address

Yes, the beneficiary has received or is currently
certified to receive the following benefits:

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

Apt.

Ste.

Flr.

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

Has the beneficiary, since obtaining the nonimmigrant
status that you seek to extend or that you seek to change
on behalf of the beneficiary, received, or is the
beneficiary currently certified to receive, any of the
following public benefits (select all that apply)?

Any Federal, State, Local or Tribal Cash
Assistance For Income Maintenance
Supplemental Security Income (SSI)

6.e. ZIP Code

Province

6.g. Postal Code
6.h. Country

7.

Country of Birth

8.

Country of Citizenship or Nationality

Form I-129CW 08/01/18

Temporary Assistance for Needy Families
(TANF)
General Assistance (GA)
Supplemental Nutrition Assistance Program
(SNAP, formerly called “Food Stamps”)
Section 8 Housing Assistance under the Housing
Choice Voucher Program
Section 8 Project-Based Rental Assistance
(including Moderate Rehabilitation)

Page 12 of 15

C.

Part 2. Information about the Additional
Beneficiary's Public Benefits (continued)

Agency that Granted the Benefit

Public Housing under the Housing Act of 1937,
42 U.S.C. 1437 et seq.
Federally-Funded Medicaid

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)

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No, the beneficiary has not received any of the above
listed public benefits.
No, the beneficiary is not certified to receive any of
the above listed public benefits.
2.

Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

If the beneficiary has received or is currently certified to
receive any of the above public benefits, provide
information about the public benefits, below. If you need
additional space to complete any Item Number in this
Part, use the space provided in Part 10. Additional
Information. Submit evidence as outlined in the
Instructions.

A.

Type of Benefit

D.

Type of Benefit

Agency that Granted the Benefit

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)

Type of Benefit

Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

Agency that Granted the Benefit

3.

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)
B.

Type of Benefit

If you answered “Yes” to Item Number 1., do any of the
following apply to the beneficiary? Provide the evidence
listed in the Form I-129CW Instructions.
The beneficiary is enlisted in the U.S. Armed Forces,
or is serving in active duty or in the Ready Reserve
Component of the U.S. Armed Forces.

The beneficiary is the spouse or the child of an
individual who is enlisted in the U.S. Armed Forces,
or who is serving in active duty or in the Ready
Reserve Component of the U.S. Armed Forces.

Agency that Granted the Benefit

At the time the beneficiary received the public
benefits, the beneficiary (or the beneficiary's spouse
or parent) was enlisted in the U.S. Armed Forces, or
was serving in active duty or in the Ready Reserve
Component of the U.S. Armed Forces.

Date the Beneficiary Started Receiving the Benefit
or if Certified, Date the Beneficiary Will Start
Receiving the Benefit
(mm/dd/yyyy)

At the time the beneficiary received the public
benefits, the beneficiary was present in the United
States in a status exempt from the public charge
ground of inadmissibility.

Date Benefit or Coverage Ended or Expires
(mm/dd/yyyy)

Form I-129CW 08/01/18

At the time the beneficiary received the public
benefits, the beneficiary was previously present in the
United States after being granted a waiver of the
public charge ground of inadmissibility.

Page 13 of 15

Part 2. Information about the Additional
Beneficiary's Public Benefits (continued)

If you answered “Yes” to Item Number 3., select any applicable
box in Item Numbers 4.a. - 4.c. and provide an answer.
4.a.

The beneficiary is a child currently residing abroad
who entered the United States with a nonimmigrant
visa to attend an N-600K, Application for Citizenship
and Issuance of Certificate Under INA Section 322,
interview.

The beneficiary is deaf or hard of hearing and requests
the following accommodation. (If they are requesting
a sign-language interpreter, indicate for which
language (for example, American Sign Language).)

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None of the above statements apply to the
beneficiary.

4.a. Has the beneficiary received, applied for, or has been
certified to receive federally-funded Medicaid in
connection with any of the following (select all that
apply):

4.b.

The beneficiary is blind or has low vision and
requests the following accommodation:

4.c.

The beneficiary has another type of disability and/or
impairment. (Describe the nature of their disability
and/or impairment and the accommodation you are
requesting.)

NOTE: Submit evidence as outlined in the Instructions.
An Emergency Medical Condition

For a Service Under the Individuals with Disabilities
Education Act (IDEA)
Other School-based Benefits or Services Available
Up to the Oldest Age Eligible for Secondary
Education Under State Law
While Under 21 Years of Age

While Pregnant or During the 60-day Period
Following the Last Day of Pregnancy
4.b. Provide the Applicable Dates
Start Date (mm/dd/yyyy)

End Date (mm/dd/yyyy)

Part 3. Accommodations for Individuals With
Disabilities and/or Impairments
NOTE: Read the information in the Form I-129CW
Instructions before completing this part.
1.

Name of Employer or Organization Filing Petition

2.

Name of Person For Whom You Are Filing

3.

Are you, the petitioning employer, requesting an
accommodation because of the beneficiary's disabilities
and/or impairments?
Yes
No

Form I-129CW 08/01/18

Part 4. Employer Attestation

Employer Attestation

There are no qualified U.S. workers available to fill the position
offered by the above named petitioning employer.
The above named petitioning employer is doing business as
defined in the regulations at 8 CFR 214.2(w)(1)(ii).
The above named petitioning employer is a legitimate business
as defined in the regulations at 8 CFR 214.2(w)(1)(vi).
The above named petitioning employer is an eligible employer
as described in 8 CFR 214.2(w)(4) and will continue to comply
with the requirements for an eligible employer until such time
as the employer no longer employs any CW-1 nonimmigrant
worker.

The beneficiary meets the qualifications for the position.
The beneficiary, if present in the CNMI, is lawfully present in
the CNMI.
The position is not temporary or seasonal employment, and the
above named petitioning employer does not reasonably believe
the position to qualify for any other nonimmigrant worker
classification.
The position falls within the list of occupational categories
designated by the Secretary at 8 CFR 214.2(w)(1)(ix).
Select only one box:
1.a.

Professional, Technical, or Management Occupations

1.b.

Clerical and Sales Occupations

1.c.

Service Occupations

1.d.

Agricultural, Fisheries, Forestry, and Related
Occupations

1.e.

Processing Occupations

1.f.

Machine Trade Occupations
Page 14 of 15

Part 3. Accommodations for Individuals With
Disabilities and/or Impairments (continued)
1.g.

Benchwork Occupations

1.h.

Structural Occupations

1.i.

Miscellaneous Occupations

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I certify under penalty of perjury, under the laws of the United
States of America, that the contents of this attestation and the
evidence submitted with it are true and correct to the best of my
knowledge. If filing on behalf of an organization, I certify that I
am empowered to do so by the organization. If this petition is to
extend a prior petition, I certify that the proposed employment is
under the same terms and conditions as stated in the prior
approved petition. I authorize the release of any information
from my records, or from the petitioning organization's record
that U.S. Citizenship and Immigration Services needs to
determine eligibility for the benefit sought.
2.

Petitioner's Printed Name

3.

Title

4.

Employer/Organization Name

Employer/Organization's Physical Address
5.a. Street Number
and Name
5.b.

Apt.

Ste.

Flr.

5.c. City or Town
5.d. State

5.e. ZIP Code

Employer/Organization's Contact Information
6.

Daytime Telephone Number

7.

Fax Number (if any)

8.

Email Address (if any)

Petitioner's Signature
9.a. Petitioner's Signature

9.b. Date of Signature (mm/dd/yyyy)
Form I-129CW 08/01/18

Page 15 of 15