Form I-130A Supplemental Information for Spouse Beneficiary

Supplemental Information for Spouse Beneficiary
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-130A

OMB No. 1615-0012
Expires 07/31/2018

To be completed by an attorney or accredited representative (if any).
Volag Number
(if any)

Select this box if
Form G-28 is
attached.

Attorney State Bar Number
(if applicable)

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

► START HERE - Type or print in black ink.
The purpose of this form is to collect additional information for a spouse beneficiary of Form I-130, Petition for Alien Relative. If
your spouse is a U.S. citizen, lawful permanent resident, or non-citizen U.S. national who is filing Form I-130 on your behalf, you
must complete and sign Form I-130A, Supplemental Information for Spouse Beneficiary, and submit it with the Form I-130 filed by
your spouse. If you reside overseas, you still must complete Form I-130A, but you do not need to sign the form.

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Part 1. Information About You (Spouse
Beneficiary)
1.

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

2.

USCIS Online Account Number (if any)
►

6.f.

Apt.

Ste.

Flr.

6.e. ZIP Code

Province

6.g. Postal Code
6.h. Country

Address History

Provide your physical addresses for 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 7. Additional Information.
Physical Address 1

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

Last Physical Address Outside the United States

4.a. Street Number
and Name
Ste.

Flr.

4.c. City or Town

4.f.

6.a. Street Number
and Name

6.d. State

3.c. Middle Name

4.d. State

Physical Address 2

6.c. City or Town

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

Apt.

5.b. Date To (mm/dd/yyyy)

6.b.

Your Full Name

4.b.

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

4.e. ZIP Code

Province

4.g. Postal Code
4.h. Country

Form I-130A 02/27/17 N

Provide your last address outside the United States of more than
one year (even if listed above).
8.a. Street Number
and Name
8.b.

Apt.

Ste.

Flr.

8.c. City or Town
8.d. Province
8.e. Postal Code
8.f.

Country

Page 1 of 6

Part 1. Information About You (The Spouse
Beneficiary)
9.a. Date From (mm/dd/yyyy)
9.b. Date To (mm/dd/yyyy)

Information About Parent 1

Part 2. Information About Your Employment
Provide your employment history for the last five years,
whether inside or outside the United States. Provide your
current employment first. If you are currently unemployed,
type or print "Unemployed" in Item Number 1. below. If you
need extra space to complete this section, use the space
provided in Part 7. Additional Information.

Full Name of Parent 1

Employment History

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

Employer 1

10.c. Middle Name

1.

Name of Employer/Company

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11.

Date of Birth (mm/dd/yyyy)

12.

Sex

13.

City/Town/Village of Birth

14.

Country of Birth

15.

City/Town/Village of Residence

16.

Country of Residence

Male

Female

2.a. Street Number
and Name

2.b.

Apt.

Ste.

Flr.

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

2.e. ZIP Code

Province

2.g. Postal Code
2.h. Country

3.

Your Occupation

Information About Parent 2

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

Full Name of Parent 2

4.b. Date To (mm/dd/yyyy)

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

Employer 2
5.

17.c. Middle Name

Name of Employer/Company

18.

Date of Birth (mm/dd/yyyy)

6.a. Street Number
and Name

19.

Sex

6.b.

20.

City/Town/Village of Birth

21.

Country of Birth

Male

Female

City/Town/Village of Residence

23.

Country of Residence

Form I-130A 02/27/17 N

Ste.

Flr.

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

22.

Apt.

6.e. ZIP Code

Province

6.g. Postal Code
6.h. Country

Page 2 of 6

Part 2. Information About Your Employment
(continued)
7.

1.b.

Your Occupation

The interpreter named in Part 5. read to me every
question and instruction on this form and my answer
to every question in
,

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

a language in which I am fluent, and I understood
everything.
2.

At my request, the preparer name in Part 6.,

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

,

Part 3. Information About Your Employment
Outside the United States

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Provide your last occupation outside the United States if not
shown above. If you never worked outside the United States,
provide this information in the space provided in Part 7.
Additional Information.
1.

Name of Employer/Company

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

Apt.

Ste.

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

2.g. Postal Code
2.h. Country
3.

Flr.

2.e. ZIP Code

Province

Your Occupation

4.a. Date From (mm/dd/yyyy)
4.b. Date To (mm/dd/yyyy)

Part 4. Spouse Beneficiary's Statement, Contact
Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-130 and
Form I-130A Instructions before completing this part.

Spouse Beneficiary'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.

prepared this form for me based only upon
information I provided or authorized.

Spouse Beneficiary's Contact Information

3.

Spouse Beneficiary's Daytime Telephone Number

4.

Spouse Beneficiary's Mobile Telephone Number (if any)

5.

Spouse Beneficiary's Email Address (if any)

Spouse Beneficiary'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 form,
in supporting documents, and in my USCIS records to other
entities and persons where necessary for the administration and
enforcement of U.S. immigration laws.

I certify, under penalty of perjury, that I provided or authorized
all of the information in this form, I understand all of the
information contained in, and submitted with, my form, and that
all of this information is complete, true, and correct.

Spouse Beneficiary's Signature

6.a. Spouse Beneficiary's Signature (sign in ink)

6.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL SPOUSE BENEFICIARIES: If you do not
completely fill out this form or fail to submit required documents
listed in the Instructions, USCIS may deny the Form I-130 filed
on your behalf.

I can read and understand English, and I have read
and understand every question and instruction on this
form and my answer to every question.

Form I-130A 02/27/17 N

Page 3 of 6

Part 5. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter you used
to complete Form I-130A if he or she is different from the
interpreter used to complete the Form I-130 filed on your behalf.

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

Interpreter's Mailing Address

3.b.

Apt.

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

Province

3.g. Postal Code
3.h. Country

Ste.

I certify, under penalty of perjury, that:
I am fluent in English and

,

which is the same language provided in Part 4., Item Number
1.b., and I have read to this spouse beneficiary in the identified
language every question and instruction on this form and his or
her answer to every question. The spouse beneficiary informed
me that he or she understands every instruction, question, and
answer on the form, including the Spouse Beneficiary's
Certification, and has verified the accuracy of every answer.

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Interpreter's Business or Organization Name (if any)

3.a. Street Number
and Name

Interpreter's Certification

Flr.

3.e. ZIP Code

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 Signature

7.a. Interpreter's Signature (sign in ink)

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

Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Spouse Beneficiary

Provide the following information about the preparer you used
to complete Form I-130A if he or she is different from the
preparer used to complete the Form I-130 filed on your behalf.

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.

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-130A 02/27/17 N

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Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Spouse Beneficiary (continued)
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)

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Preparer's Statement
7.a.

I am not an attorney or accredited representative but
have prepared this form on behalf of the spouse
beneficiary and with the spouse beneficiary's consent.

7.b.

I am an attorney or accredited representative and my
representation of the spouse beneficiary in this case
extends
does not extend beyond the preparation
of this form.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this form, you may be obliged to submit
a completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative,
with this form.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I
prepared this form at the request of the spouse beneficiary. The
spouse beneficiary then reviewed this completed form and
informed me that he or she understands all of the information
contained in, and submitted with, his or her form, including the
Spouse Beneficiary's Certification, and that all of this
information is complete, true, and correct. I completed this
form based only on information that the spouse beneficiary
provided to me or authorized me to obtain or use.

Preparer's Signature
8.a. Preparer's Signature (sign in ink)

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

Form I-130A 02/27/17 N

Page 5 of 6

5.a. Page Number

Part 7. Additional Information
If you need extra space to provide any additional information
within this form, 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 form 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
2.

5.d.

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A-Number (if any) ► A-

3.a. Page Number
3.d.

4.a. Page Number
4.d.

5.b. Part Number 5.c. Item Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number 6.c. Item Number

6.d.

4.b. Part Number 4.c. Item Number

Form I-130A 02/27/17 N

7.a. Page Number

7.b. Part Number 7.c. Item Number

7.d.

Page 6 of 6