Table of Changes (Form)

TABLE OF CHANGES – FORM

Form I-912, Request for Fee Waiver

OMB Number: 1615-0116

09/06/2019

Reason for Revision: SPC Revision.

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
Page 1, START HERE	[Page 1] START HERE - Type or print in black ink. If you need extra space to complete any section of this request or if you would like to provide additional information about your circumstances, use the space provided in Part 11. Additional Information. Complete and submit as many copies of Part 11., as necessary, with your request.	[Page 1] START HERE - Type or print in black ink. If you need extra space to complete any section of this request or if you would like to provide additional information about your circumstances, use the space provided in Part 8. Additional Information. Complete and submit as many copies of Part 8., as necessary, with your request.
Page 1, Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the Form I-912 Instructions)	[Page 1] Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the Form I-912 Instructions) Select at least one basis or more for which you may qualify and provide supporting documentation for any basis you select. You only need to qualify and provide documentation for one basis for U.S. Citizenship and Immigration Services (USCIS) to grant your fee waiver. If you choose, you may select more than one basis; you must provide supporting documentation for each basis you want considered. 1. [ ] I am, my spouse is, or the head of household living in my household is currently receiving a means-tested benefit. (Complete Parts 2. - 4. and Parts 7. - 10.) 2. [ ] My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part 5., and 7. - 10.) 3. [ ] I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 10.)	[Page 1] Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the Form I-912 Instructions) Select at least one basis or more for which you may qualify and provide supporting documentation for any basis you select. You only need to qualify and provide documentation for one basis for U.S. Citizenship and Immigration Services (USCIS) to grant your fee waiver. If you choose, you may select more than one basis; you must provide supporting documentation for each basis you want considered. [delete] 1. [ ] My household income is at or below 150 percent of the Federal Poverty Guidelines (FPG). (Complete Parts 2. - 3., and Parts 5. - 7.) 2. [ ] I have a financial hardship. (Complete Part 2., and Parts 4. - 7.)
Pages 1-2, Part 2. Information About You (Requestor)	[Page 1] Part 2. Information About You (Requestor) Provide information about yourself if you are the person requesting a fee waiver for a petition or application you are filing. If you are the parent or legal guardian filing on behalf of a child or person with a physical disability or developmental or mental impairment, provide information about the child or person for whom you are filing this form. 1. Full Name Family Name (Last Name) Given Name (First Name) Middle Name 2. Other Names Used (if any) List all other names you have used, including nicknames, aliases, and maiden name. Family Name (Last Name) [x2] Given Name (First Name) [x2] Middle Name [x2] 3. Alien Registration Number (A-Number) (if any) 4. USCIS Online Account Number (if any) 5. Date of Birth (mm/dd/yyyy) 6. U.S. Social Security Number (if any) [Page 2] 7. Marital Status Single, Never Married Married Divorced Widowed Marriage Annulled Separated Other (Explain) [new]	[Page 1] Part 2. Information About You (Requestor) Provide information about yourself if you are requesting a fee waiver for a petition or application you are filing. If you are a parent or legal guardian filing for a child or person with a physical disability or developmental or mental impairment, provide information about the child or person for whom you are filing this request. 1. Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name 2. Other Names Used (if any) Provide all other names you have ever used, including aliases, maiden name, and nicknames. [no change] 8. List and provide the total number of applications and petitions for which you are requesting a fee waiver. [Table: 4 rows, 2 columns: Form and Number; last column, Total Number] 9. Are you applying for or have status or a granted approval as a battered spouse of an A, G, E-3, or H nonimmigrants; a battered spouse or child of a lawful permanent resident or U.S. citizen under INA section 240A(b)(2); a T nonimmigrant; a person with Temporary Protected Status; a U nonimmigrant; or a VAWA self–petitioner? Yes No A. Receipt Number (if applicable)
Page 2, Part 3. Applications and Petitions for Which You Are Requesting a Fee Waiver	[Page 2] Part 3. Applications and Petitions for Which You Are Requesting a Fee Waiver 1. In the table below, add the form numbers of the applications and petitions for which you are requesting a fee waiver. [Table: Applications or Petitions for You and Your Family Members; 3 rows; 5 columns: Full Name, A-Number (if any), Date of Birth, Relationship to You [Self], Forms Being Filed; Last Row: Total Number of Forms (including self)]	[Page 2] [delete]
Page 2, Part 4. Means-Tested Benefits	[Page 2] Part 4. Means-Tested Benefits If you selected Item Number 1. in Part 1., complete this section. 1. If you, your spouse, or the head of household (including parent if the child is under 21 years of age) living with you is receiving any means-tested benefits, list the information in the table below and attach supporting documentation. If you are the parent or legal guardian filing on behalf of a child or person with a physical disability or developmental or mental impairment, provide information about the child or person for whom you are filing this form if he or she is receiving a means-tested benefit. [Table: Means-Tested Benefit Recipients; 4 rows; 6 columns: Full Name of Person Receiving the Benefit, Relationship to You, Name of Agency Awarding Benefit, Type of Benefit, Date Benefit was Awarded, Date Benefit Expires (or must be renewed)]	[Page 2] [delete]
Pages 2-4, Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines	[Page 2] Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines If you selected Item Number 2. in Part 1., complete this section. Your Employment Status 1. Employment Status Employed (full-time, part-time, seasonal, self-employed) Unemployed or Not Employed Retired Other (Explain) [Page 3] 2. If you are currently unemployed, are you currently receiving unemployment benefits? Yes No A. Date you became unemployed (mm/dd/yyyy) Information About Your Spouse 3. If you are married or separated, does your spouse live in your household? Yes No A. If you answered “No” to Item Number 3., does your spouse provide any financial support to your household? Yes No Your Household Size 4. Are you the person providing the primary financial support for your household? Yes No If you answered “Yes” to Item Number 4., type or print your name on the line marked “self” in the table below. If you answered “No” to Item Number 4., type or print your name on the line marked “self” in the table below and add the head of household's name on the line below yours. [Table: Household Size, 4 rows, 6 columns: Full Name, Date of Birth, Relationship to You [Self], Married [Yes/No], Full-Time Student [Yes/No], Is any income earned by this person counted towards the household income? [Yes/No]; Last row: Total Household Size (including self)] Your Annual Household Income [new] Provide information about your income and the income of all family members counted as part of your household. You must list all amounts in U.S. dollars. 5. Your Annual Income 6. Annual Income of All Family Members Provide the annual income of all family members counted as part of your household as listed in Item Number 4. (Do not include the amount provided in Item Number 5.) 7. Total Additional Income or Financial Support Provide the total annual amount you receive in additional income or financial support from a source outside of your household. (Do not include the amount provided in Item Numbers 5. or 6.) You must add all of the additional income and financial support amounts and put the total amount in the space provided. Type or print "0" in the total box if there are none. Select the type of additional income or financial support that you receive and provide documentation. Parental Support Spousal Support (Alimony) Child Support Educational Stipends Royalties Pensions Unemployment Benefits Social Security Benefits Veteran's Benefits Financial Support From Adult Children, Dependents, Other People Living in the Household Other (Explain) [Page 4] 8. Total Household Income (add the amounts from Item Numbers 5., 6., and 7.) 9. Has anything changed since the date you filed your Federal tax returns? (For example, your marital status, income, or number of dependents.) Yes No If you answered "Yes" to Item Number 9., provide an explanation below. Provide documentation if available. You may also use this space to provide any additional information about your circumstances that you would like USCIS to consider.	[Page 2] Part 3. Household Income [delete] [no change] 2. If you are currently unemployed, since when have you been unemployed (mm/dd/yyyy)? [delete] A. If you are currently unemployed, are you currently receiving unemployment benefits? Yes No [no change] 3. If you are married or separated, does your spouse live in your household? Yes (add your spouse to the table below and provide his or her income in Item Number 9. below) No A. If you answered “No” to Item Number 3., does your spouse provide any financial support to your household? Yes (provide financial support income in Item Number 10. below) No Your Household Size 4. Are you the person providing the primary financial support for your household? Yes No If you answered “Yes” to Item Number 4., type or print your name on the line marked “self” in the table below. Also provide income in Item Number 8. below. If you answered “No” to Item Number 4., type or print your name on the line marked “self” in the table below and add the head of household's name on the line below yours. [Page 3] [no change] Your Annual Household Income 5. Did you file a federal tax return for the last year? Yes No If you answered “No” to Item Number 5., provide an answer to Item Number 7. 6. Did your household members file tax returns for the last year? Yes No If you answered “No” to Item Number 6., provide an answer to Item Number 7. If you answered “No” to Item Number 6., which household member(s) did not file a tax return? 7. If you or your household member did not file a tax return for the last year, select the reason for not filing and provide an explanation. See I-912 Instructions for required documentation. I/we plan to file the tax return before the due date this year. I/we are not required to file a tax return for the current or previous year. I/we filed for an extension. I/we are not going to file. Explanation: Provide information about your income and the income of all family members counted as part of your household. You must list all amounts in U.S. dollars. 8. Your Annual Income 9. Annual Income of All Family Members Counted as Part of Your Household (Do not include the amount provided in Item Number 8.) 10. Total Additional Income or Financial Support (Do not include the amount provided in Item Numbers 8. or 9.) If you received additional income on a continuing monthly or annual basis for the most recent full year, and it is NOT listed in your Federal tax return, provide the amount of additional income below (for example, child support). Attach evidence of the additional income. You must add all of the additional income and financial support amounts and put the total amount in the space provided. Type or print "0" in the total box if no additional income is received. [Table, 12 rows, 2 columns: Type of Income, Annual Amount (in dollars); last row, Total Additional Income and Financial Support] [1st column should read: Parental Support, Yes/No Spousal Support (Alimony), Yes/No Child Support, Yes/No Educational Stipends, Yes/No Royalties, Yes/No Pensions, Yes/No Unemployment Benefits, Yes/No Social Security Benefits, Yes/No Veteran's Benefits, Yes/No Financial Support from Adult Children, Dependents, Other People Living in the Household, Yes/No Other, Yes/No, Explanation] [Page 4] 11. Total Annual Household Income (add the amounts from Item Numbers 8., 9., and 10.) 12. Has anything changed since the date you filed your Federal tax returns? (For example, your marital status, income, or number of dependents.) Yes No If you answered "Yes" to Item Number 12., provide an explanation below. Provide documentation if available. You may also use this space to provide any additional information about your circumstances that you would like U.S. Citizenship and Immigration Services (USCIS) to consider.
Pages 4-5, Part 6. Financial Hardship	[Page 4] Part 6. Financial Hardship If you selected Item Number 3. in Part 1., complete this section. 1. If you or any family members have a situation that has caused you to incur expenses, debts, or loss of income, describe the situation in the box below. Specify the amounts of the expenses, debts, and income losses in as much detail as possible. Examples may include medical expenses, job loss, eviction, and homelessness. 2. If you have cash or assets that you can quickly convert to cash, list those in the table below. For example, bank accounts, stocks, or bonds. (Do not include retirement accounts.) [Table: Assets; 3 rows, 2 columns: Type of Asset, Value (U.S. Dollars); last row: Total Value of Assets] [Page 5] 3. Total Monthly Expenses and Liabilities Provide the total monthly amount of your expenses and liabilities. You must add all of the expense and liability amounts and type or print the total amount in the space provided. Type or print "0" in the total box if there are none. Select the types of expenses or liabilities you have each month and provide evidence of monthly payments, where possible. Rent and/or Mortgage Loans and/or Credit Cards Other _____________ Food Car Payment Utilities Commuting Cost Child and/or Elder Care Medical Expenses Insurance School Expenses	[Page 4] Part 4. Financial Hardship If you selected Item Number 2. in Part 1., complete this section. 1. If you or any family members have a situation that has caused you to incur expenses, debts, or loss of income, describe the situation in the box below. Specify the amounts of the expenses, debts, and income losses in as much detail as possible. Examples may include medical expenses, job loss, eviction, victimization, and homelessness. 2. If you have cash or assets that you can quickly convert to cash, list those in the table below. For example, bank accounts, stocks, or bonds. (Do not include retirement accounts.) [Table: Assets; 3 rows, 2 columns: Type of Asset, Value (U.S. Dollars); last row: Total Value of Assets] [Page 5] 3. Total Monthly Expenses and Liabilities Provide the total monthly amount of your expenses and liabilities. You must add all of the expense and liability amounts and type or print the total amount in the space provided. Type or print "0" in the total box if there are none. Select the types of expenses or liabilities you have each month and provide evidence of monthly payments, where possible. Rent and/or Mortgage Loans and/or Credit Cards Other _____________ Food Car Payment Utilities Commuting Cost Child and/or Elder Care Medical Expenses Insurance School Expenses
Pages 5-6, Part 7. Requestor's Statement, Contact Information, Certification, and Signature	[Page 5] Part 7. Requestor's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part. Each person applying for a fee waiver request must complete, sign, and date Form I-912 and provide the required documentation. This includes family members identified in Part 3. Signature fields for family members are at the end of this part. If an individual is under 14 years of age, a parent or legal guardian may sign the request on their behalf. USCIS rejects any Form I-912 that is not signed by all individuals requesting a fee waiver and may deny a request that does not provide required documentation. Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Requestor's Statement Regarding the Interpreter A. I can read and understand English, and I have read and understand every question and instruction on this request and my answer to every question. B. The interpreter named in Part 9. read to me every question and instruction on this request and my answer to every question in [fillable field], a language in which I am fluent, and I understood everything. 2. Requestor's Statement Regarding the Preparer (if applicable) At my request, the preparer named in Part 10., [fillable field], prepared this request for me based only upon information I provided or authorized. Requestor's Contact Information 3. Requestor's Daytime Telephone Number 4. Requestor's Mobile Telephone Number (if any) 5. Requestor's Email Address (if any) Requestor'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 request, 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 my request, I understand all of the information contained in, and submitted with, my request, and that all of this information is complete, true, and correct. [Page 6] WARNING: If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-912, USCIS will deny your fee waiver request and may deny any other immigration benefit. In addition, you may face severe penalties provided by law and may be subject to criminal prosecution. Requestor's Signature 6. Requestor's Signature Date of Signature (mm/dd/yyyy) NOTE TO ALL REQUESTORS: If you do not completely fill out this request or fail to submit required documents listed in the Instructions, USCIS may deny your request. Family Members’ Signatures NOTE: Each family member must type or print their full name and sign the spaces below. You can find additional family members’ signature spaces in Item Number 7. - 10. below. All family members identified in Part 3. must sign and date Form I-912. I certify that the information provided by the requestor in Part 7. applies to me. 7. Family Member 1 Family Member's Name Family Member's Signature Date of Signature (mm/dd/yyyy) 8. Family Member 2 Family Member's Name Family Member's Signature Date of Signature (mm/dd/yyyy) 9. Family Member 3 Family Member's Name Family Member's Signature Date of Signature (mm/dd/yyyy) 10. Family Member 4 Family Member's Name Family Member's Signature Date of Signature (mm/dd/yyyy) 11. Family Member 5 Family Member's Name Family Member's Signature Date of Signature (mm/dd/yyyy)	[Page 6] Part 5. Requestor's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-912 Instructions before completing this section. You must complete, sign, and date Form I-912 and provide the required documentation. If an individual is under 14 years of age, a parent or legal guardian may sign the request on their behalf. USCIS rejects any Form I-912 that is not signed and may deny a request that does not provide required documentation. NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. [no change] B. The interpreter named in Part 6. read to me every question and instruction on this request and my answer to every question in [fillable field], a language in which I am fluent, and I understood everything. 2. Requestor's Statement Regarding the Preparer At my request, the preparer named in Part 7., [fillable field], prepared this request for me based only upon information I provided or authorized. [no change] Requestor'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 and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I further authorize release of information contained in this request, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration and enforcement of U.S. immigration law. [no change] [Page 6] [delete]
Page 7, Part 8. Family Member's Statement, Contact Information, Certification, and Signature	[Page 7] Part 8. Family Member's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part. If the information provided by the requestor in Part 7. is not applicable to a family member identified in Part 3., (for example, the family member used an interpreter or speaks a different language) that individual should complete Part 8. USCIS rejects any Form I-912 that is not signed by all individuals requesting a fee waiver. Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2. 1. Family Member's Statement Regarding the Interpreter for [fillable field] A. I can read and understand English, and I have read and understand every question and instruction on this request and my answer to every question. B. The interpreter named in Part 9. read to me every question and instruction on this request and my answer to every question in [fillable field] , a language in which I am fluent, and I understood everything. 2. Family Member's Statement Regarding the Preparer for [fillable field] At my request, the preparer named in Part 10., [fillable field], prepared this request for me based only upon information I provided or authorized. Family Member's Contact Information 3. Family Member's Daytime Telephone Number 4. Family Member's Mobile Telephone Number (if any) 5. Family Member's Email Address (if any) Family Member'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 request, 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 my request, I understand all of the information contained in, and submitted with, my request, and that all of this information is complete, true, and correct. Family Member's Signature 6. Family Member's Signature Date of Signature (mm/dd/yyyy) NOTE TO ALL FAMILY MEMBERS: If you do not completely fill out this request or fail to submit required documents listed in the Instructions, USCIS may deny your request.	[Page 7] [delete]
Page 8, Part 9. Interpreter's Contact Information, Certification, and Signature	[Page 8] Part 9. Interpreter's Contact Information, Certification, and Signature 1. Did any person filing this request use an interpreter? Yes, (complete this section) No (skip to Part 10.) 2. Was the same interpreter used for all individuals requesting a fee waiver (as listed in Part 3.)? Yes No NOTE for Family Members: If you used a different interpreter than the one used by the requestor, make additional copies of Part 9., provide the following information, indicate the family member for whom he or she interpreted, and include the pages with your completed Form I-912. Provide the following information about the interpreter for [fillable field] Interpreter's Full Name 3. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 4. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 5. Street Number and Name Apt Ste Flr City or Town State ZIP Code Province Postal Code Country Interpreter's Contact Information 6. Interpreter's Daytime Telephone Number 7. Interpreter's Mobile Telephone Number (if any) 8. 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 7., Item B. in Item Number 1., and I have read to this requestor in the identified language every question and instruction on this request and his or her answer to every question. The requestor informed me that he or she understands every instruction, question, and answer on the request, including the Applicant's Certification, and has verified the accuracy of every answer Interpreter's Signature 9. Interpreter's Signature Date of Signature (mm/dd/yyyy)	[Page 7] Part 6. Interpreter's Contact Information, Certification, and Signature [delete] 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 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 5., Item B. in Item Number 1., and I have read to this requestor in the identified language every question and instruction on this request and his or her answer to every question. The requestor informed me that he or she understands every instruction, question, and answer on the request, including the Requestor’s Certification, and has verified the accuracy of every answer Interpreter's Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy)
Pages 9-10, Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other Than the Requestor	[Page 9] Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other Than the Requestor 1. Did any person prepare this request on your behalf? Yes, (complete this section) No, skip 2. Was the same preparer used for all individuals requesting a fee waiver (as listed in Part 3.)? Yes No NOTE for Family Members: If you used a different preparer than the one used by the requestor, provide the following information, and include the pages with your completed Form I-912. Provide the following information about the preparer for [fillable field] Preparer's Full Name 3. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 4. Preparer's Business or Organization Name (if any) Preparer's Mailing Address 5. Street Number and Name Apt Ste Flr City or Town State ZIP Code Province Postal Code Country Preparer's Contact Information 6. Preparer's Daytime Telephone Number 7. Preparer's Mobile Telephone Number (if any) 8. Preparer's Email Address (if any) Preparer's Statement 9. A. I am not an attorney or accredited representative but have prepared this request on behalf of the requestor and with the requestor's consent. B. I am an attorney or accredited representative and my representation of the requestor in this case extends/does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative, 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 request. [Page 10] Preparer’s Certification By my signature, I certify, under penalty of perjury, that I prepared this request at the request of the requestor. The requestor then reviewed this completed request and informed me that he or she understands all of the information contained in, and submitted with, his or her request, including the Applicant's Certification, and that all of this information is complete, true, and correct. I completed this request based only on information that the requestor provided to me or authorized me to obtain or use. Preparer's Signature 10. Preparer's Signature Date of Signature (mm/dd/yyyy)	[Page 7] Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other Than the Requestor [delete] 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) [Page 8] Preparer's Mailing Address 3. Street Number and Name Apt Ste Flr City or Town State ZIP Code Province Postal Code 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 request on behalf of the requestor and with the requestor's consent. B. I am an attorney or accredited representative and my representation of the requestor in this case extends/does not extend beyond the preparation of this request. 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 G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States, with this request. Preparer’s Certification By my signature, I certify, under penalty of perjury, that I prepared this request at the request of the requestor. The requestor then reviewed this completed request and informed me that he or she understands all of the information contained in, and submitted with, his or her request, including the Requestor’s Certification, and that all of this information is complete, true, and correct. I completed this request based only on information that the requestor provided to me or authorized me to obtain or use. Preparer's Signature 8. Preparer's Signature Date of Signature (mm/dd/yyyy)
Page 11, Part 11. Additional Information	[Page 11] Part 11. Additional Information If you need extra space to provide any additional information within this request, 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 request or attach a separate sheet of paper. Include your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers. 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. [Fillable field] 4. A. Page Number B. Part Number C. Item Number D. [Fillable field] 5. A. Page Number B. Part Number C. Item Number D. [Fillable field] 6. A. Page Number B. Part Number C. Item Number D. [Fillable field]	[Page 9] Part 8. Additional Information If you need extra space to provide any additional information within this request, 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 request 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. [no change]

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