Form I-941 Application for Entrepreneur Parole

USCIS
Form I-941

Application for Entrepreneur Parole
Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0136
Expires 04/30/2022

Receipt

For
USCIS
Use
Only

Action Block

DRAFT
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Production
06/10/2020
Remarks

To be completed by an
attorney or accredited
representative.

Select this box if
Form G-28 or
G-28I is attached.

Attorney State Bar Number

Attorney or Accredited Representative
USCIS Online Account Number

► START HERE - Type or print in black ink.

Part 1. Information About the Entrepreneur
(Applicant)
I am requesting:
1.a.

Initial Parole
OR
Re-Parole

1.b.
OR
1.c.

Amended Application

If you are requesting a re-parole or filing an amended application,
provide the Receipt Number of your current Form I-941 approval
in Item Number 2. below.
2.

Receipt Number
►

Your Full Name
3.a. Family Name
(Last Name)
3.b. Given Name
(First Name)
3.c. Middle Name

Other Names Used

Provide any other names you have used since birth, including
aliases, maiden names, and nicknames. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

4.c. Middle Name

Other Information
5.

Alien Registration Number (A-Number)
► A-

6.

USCIS Online Account Number
►

7.

U.S. Social Security Number
►

8.

Date of Birth (mm/dd/yyyy)

9.

Sex

10.

Marital Status
Single

Form I-941 04/24/19

Male

Married

Female

Divorced

Widowed

Page 1 of 15

Where do you want USCIS to send all travel documents for
you, and your spouse and dependent children?

Part 1. Information About the Entrepreneur
(Applicant) (continued)
11.

18.a.

To the U.S. address in Part 1., Item Numbers
19.a. - 19.f.

18.b.

To a U.S. Embassy or U.S. Consulate at:

Country of Birth

12.

Country of Citizenship or Nationality

13.

Date of Last Arrival in the United States

Name of U.S. Embassy or U.S. Consulate

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18.c.

(mm/dd/yyyy)
14.

Current or Last Class of Admission (for example, B-1,
F-1, H-1B)

15.

If you are present in the United States, other than on the
basis of an Entrepreneur Parole, provide the receipt number
of your most recent filing with USCIS.
►

To a Department of Homeland Security (DHS) office
overseas at:
Name of DHS Office

Entrepreneur's Current U.S. Mailing Address

19.a. In Care Of Name

19.b. Street Number
and Name

Provide information about your most recent Form I-94 ArrivalDeparture Record, in Item Numbers 16.a. - 16.f.

19.c.

16.a. Form I-94 Arrival-Departure Record Number

19.d. City or Town

►
16.b. Passport Number

Apt.

Ste.

19.e. State

Flr.

19.f. ZIP Code

(USPS ZIP Code Lookup)

Entrepreneur's Current Physical Address

16.c. Travel Document Number

20.a. Street Number
and Name

16.d. Country of Issuance for Passport or Travel Document

20.b.

Apt.

Ste.

Flr.

20.c. City or Town
16.e. Expiration Date for Passport or Travel Document
20.d. State

(mm/dd/yyyy)

20.e. ZIP Code

20.f. Province

16.f. Date that Authorized Stay Expired or Will Expire as
Shown on Form I-94 or I-95 (mm/dd/yyyy)

20.g. Postal Code
17.a. Have you, or any person included in this application, ever
been in exclusion, deportation, removal, or rescission
proceedings, or are you now in such proceedings?
Yes

No

If you answered "Yes," to Item Number 17.a., provide
the following information below:
17.b. Name of the Person in Proceedings

Form I-941 04/24/19

20.h. Country

Entrepreneur's Education
21.

Name of Institution of Higher Learning

22.

Type of Degree/Major Field of Study

23.

Date Degree Received (mm/dd/yyyy)

Page 2 of 15

Part 1. Information About the Entrepreneur
(Applicant) (continued)

Part 3. Information About Family Members
Requesting Parole or Re-Parole with
Entrepreneur

School Address
Entrepreneur's Spouse's Information

24.a. Street Number
and Name
24.b.

Apt.

Ste.

24.c. City or Town
24.d. State

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

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Flr.

1.c. Middle Name

24.e. ZIP Code

2.

24.f. Province

A-Number

► A-

24.g. Postal Code

3.

USCIS Online Account Number
►

24.h. Country

4.

Date of Birth (mm/dd/yyyy)

5.

Country of Birth

6.

Country of Citizenship or Nationality

Part 2. Biographic Information
1.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

2.

Entrepreneur's Spouse's Other Names Used

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

4.

Weight

Pounds

5.

Eye Color (Select only one box)
Black
Gray
Maroon

6.

Inches

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

7.c. Middle Name

Blue
Green
Pink

Brown
Hazel
Unknown/Other

Hair Color (Select only one box)
Bald (No hair)
Brown
Sandy

Provide any other names your spouse has used since birth,
including aliases, maiden names, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.

Black
Gray
White

Entrepreneur's Dependent Children
Provide the following information about each child. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
Child 1

Blond
Red
Unknown/Other

8.a. Family Name
(Last Name)
8.b. Given Name
(First Name)
8.c. Middle Name

Form I-941 04/24/19

Page 3 of 15

Part 3. Information About Family Members
Requesting Parole or Re-Parole with
Entrepreneur (continued)
9.

3.

Country of Citizenship or Nationality

4.

Receipt Number
►

A-Number
► A-

10.

►
11.

Date of Birth (mm/dd/yyyy)

12.

Country of Birth

13.

Country of Citizenship or Nationality

Child 2
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
14.c. Middle Name
15.

A-Number

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

5.c. Middle Name

6.

Date of Birth (mm/dd/yyyy)

7.

Country of Citizenship or Nationality

8.

Receipt Number
►

Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners

► A16.

Entrepreneur 2

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USCIS Online Account Number

Information About the Qualifying Start-Up Entity

1.

►
17.

Date of Birth (mm/dd/yyyy)

18.

Country of Birth

Start-Up Entity Address
2.a. Street Number
and Name
2.b.

19.

Start-Up Entity Legal Name

USCIS Online Account Number

Country of Citizenship or Nationality

Apt.

Ste.

Flr.

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

2.e. ZIP Code

Part 4. Information About Additional
Entrepreneurs Requesting or Have Been Granted
Parole or Re-Parole with the Same Start-up
Entity

3.

Federal Employer Identification Number

4.

DUNS Number

Entrepreneur 1

5.

Trade Name "DBA" (Doing Business As)

6.

Date Start-Up Entity Established in United States

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c. Middle Name
2.

(mm/dd/yyyy)
7.

Number of Full-Time Employees in United States

Date of Birth (mm/dd/yyyy)

Form I-941 04/24/19

Page 4 of 15

Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)

11.b. Amount of Qualified Government Award or Grant

8.

11.c. Date Qualified Grant or Award Received (mm/dd/yyyy)

Your Ownership Stake/Percentage of Start-Up Entity

$

%
If you need more space to complete this section, use the
space provided in Part 10. Additional Information.

Applying for Initial Parole
9.

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Explanatory Statement. Provide a detailed statement
explaining how you meet the criteria for entrepreneur
parole. Your statement should include an explanation of
your role in the operations of that entity, as well as how
your involvement with the start-up entity will advance the
start-up entity's growth and business success such as to
result in a significant public benefit. You may provide this
statement in the space provided in Part 10. Additional
Information or attach a separate sheet of paper; type or
print your name and startup entity identification number 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.

Alternative Criteria

12.a. Does your start-up entity partially meet one or both of the
above threshold criteria?
Yes
No
N/A
If you answered "Yes" to Item Number 12.a., provide
the amounts of qualified investment and/or qualified
government award or grant that was received in Item
Numbers 12.b. - 12.c.

12.b. Amount of Qualified Investment
$

12.c. Amount of Qualified Government Award or Grant
$

Applying for Re-Parole

13.

If you answered "No" to Item Number 13., explain the
current status of the start-up entity for which you were
granted initial parole in Item Number 14. If you need
more space to complete this section, use the space
provided in Part 10. Additional Information.

10.a. Did your start-up entity receive a qualified investment of
at least $250,000 within 18 months immediately
preceding the filing of this application?
Yes

No

If you answered "Yes" to Item Number 10.a., provide
the amount of qualified investment and date the qualified
investment was received in Item Numbers 10.b. - 10.c.

Is this the same start-up entity for which you were granted
an initial parole?
Yes
No

14.

Explanation

10.b. Amount of Qualified Investment
$
10.c. Date Qualified Investment Received (mm/dd/yyyy)

If you need more space to complete this section, use the
space provided in Part 10. Additional Information.
11.a. Did your start-up entity receive a qualified government
award or grant of at least $100,000 within 18 months
immediately preceding the filing of this application?
Yes

No

If you answered "Yes" to Item Number 11.a., provide
the amount of qualified government award or grant and
date the qualified government award or grant was
received in Item Numbers 11.b. - 11.c.
Form I-941 04/24/19

Re-Parole Criteria
Provide evidence that you continue to meet the definition of
entrepreneur and that your business continues to meet the
definition of start-up entity.
15.

Do you own at least 5% of the shares, or similar type of
equity interest, in the start-up entity?
Yes
No

Page 5 of 15

Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
16.

Do you continue to perform an active and central role in
the start-up entity?
Yes
No

17.

Is the start-up entity continuing to lawfully operate in the
United States?
Yes
No

23.

Provide a detailed statement explaining how you continue
to meet the criteria for entrepreneur parole. Your statement
should include an explanation of your continued or new
role in the operations of that entity, as well as how your
involvement with the start-up entity will advance the startup entity's growth and business success such as to result in
a significant public benefit. You may provide this
statement in the space provided in Part 10. Additional
Information or attach a separate sheet of paper; type or
print your name and startup entity identification number 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.

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18.a. Did your start-up entity receive at least $500,000 in
qualifying investments, qualified government awards or
grants, or a combination of such funding during the initial
parole period?
Yes
No
N/A
18.b. Provide the amounts of qualifying investments, qualified
government awards or grants.
$

19.a. Did your start-up entity create at least 10 qualified jobs
with the start-up entity during the initial parole period?
Yes

No

N/A

19.b. Provide the number of qualified jobs.

20.a. Did your start-up reach at least $500,000 in annual revenue
in the United States during the initial parole period?
Yes

No

N/A

20.b. Provide the amount of annual revenue generated.

24.a. Are you maintaining a household income that is greater
than 400 percent of the Federal Poverty Guidelines?

$

21.a. Did the annual revenue generated by your start-up entity in
the United States average 20 percent growth during the
initial parole period?
Yes
No
N/A

If you answered "Yes" to Item Number 24.a., provide
the information requested in Item Numbers 24.b. - 24.c.
$

%

Alternative Criteria
22.a. Does your start-up entity partially meet one or more of the
above threshold criteria?
Yes
No
N/A

22.b. Total Amount of Revenue Generated During Initial
Period of Parole
$

No

24.b. Amount of Household Income in Last Full Calendar Year

21.b. Provide the percentage of annual revenue growth.

If you answered "Yes" to Item Number 22.a., provide
the applicable information requested in Item Numbers
22.b. - 22.d.

Yes

24.c. Number of Members of Household

Filing an Amended Application to Report a
Material Change
In the space below, provide a detailed explanation of any material
changes to the facts on which your parole was based. If you need
more space to complete this section, use the space provided in
Part 10. Additional Information.
25.

Explanation

22.c. Total Amount of Additional Qualified Investment,
Government Grants or Awards During Initial Period of
Parole
$
22.d. Total Number of Qualified Jobs Created During Initial
Period of Parole

Form I-941 04/24/19

Page 6 of 15

Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)

31.

26.a. Are you maintaining a household income that is greater
than 400 percent of the Federal Poverty Guidelines?

32.

Date of Birth (mm/dd/yyyy)

33.

Country of Birth

Yes

No

If you answered "Yes" to Item Number 26.a., provide
the information requested in Item Numbers 26.b. - 26.c.

USCIS Online Account Number
►

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34.

Country of Citizenship or Nationality

26.b Amount of Household Income in Last Full Calendar Year
$

35.a. Percentage of Ownership in the Start-Up Entity Listed in
Part 5., Item Number 1.

26.c. Number of Members of Household

Information About the Owners of the Start-Up
Entity

35.b. Position Held in the Entity Listed in Part 5., Item
Number 1.

If there are multiple owners of the start-up entity, you must list
all other individuals or entities that own a share of the start-up
entity and identify their ownership percentage.

Address and Contact Information

Owner 1

36.a. Street Number
and Name
36.b.

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

Apt.

Ste.

Flr.

36.c. City or Town
36.d. State

27.c. Middle Name
27.d. Legal Entity Name

36.e. ZIP Code

36.f. Province

36.g. Postal Code

27.e. Trade Name "DBA" (Doing Business As)

Other Names Used
Provide any other names you have used since birth, including
aliases, maiden names, and nicknames. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.
28.a. Family Name
(Last Name)
28.b. Given Name
(First Name)

36.h. Country

37.

Daytime Telephone Number

38.

Fax Number

39.

Email Address

40.

Website Address

28.c. Middle Name

Owner 2

Other Information
29.

A-Number
► A-

30.

U.S. Social Security Number
►

Form I-941 04/24/19

41.a. Family Name
(Last Name)
41.b. Given Name
(First Name)
41.c. Middle Name

Page 7 of 15

Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
41.d. Legal Entity Name

Address and Contact Information
50.a. Street Number
and Name
50.b.

41.e. Trade Name "DBA" (Doing Business As)

Apt.

Ste.

50.c. City or Town

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50.d. State

Other Names Used

42.c. Middle Name

Other Information
43.

A-Number

► A44.

50.e. ZIP Code

50.f. Province

Provide any other names used for Owner 2 since birth,
including aliases, maiden name, and nicknames. If extra space
is needed to complete this section, use the space provided in
Part 10. Additional Information.
42.a. Family Name
(Last Name)
42.b. Given Name
(First Name)

Flr.

50.g. Postal Code
50.h. Country

51.

Daytime Telephone Number

52.

Fax Number

53.

Email Address

54.

Website Address

U.S. Social Security Number
►

45.

USCIS Online Account Number
►

Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award

46.

Date of Birth (mm/dd/yyyy)

Name of Investor (if an individual)

47.

Country of Birth

48.

Country of Citizenship or Nationality

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

49.a. Percentage of Ownership in the Start-Up Entity Listed in
Part 5., Item Number 1.

49.b. Position Held in the Entity Listed in Part 5., Item
Number 1.

2.

Date of Birth (mm/dd/yyyy)

3.

A-Number
► A-

4.

U.S. Social Security Number
►

5.

Form I-941 04/24/19

Country of Birth

Page 8 of 15

Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)

List investments in other start-ups by this investor during the
preceding five years totaling no less than $600,000. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.

Mailing Address and Contact Information

14.

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

Apt.

Ste.

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

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6.g. Postal Code
6.h. Country

15.

DUNS Number

16.

Year of Investment

17.

Amount of Investment $

18.

Type of Investment

Flr.

6.e. ZIP Code

Province

Name of Company

19.a. Street Number
and Name
19.b.

7.

Daytime Telephone Number

8.

Fax Number

Apt.

Ste.

Flr.

19.c. City or Town
19.d. State

19.e. ZIP Code

19.f. Province

9.

Email Address

10.

Website Address

19.g. Postal Code
19.h. Country

Information on Investment
11.a. Aggregate Amount of Investment
$
11.b. Types of Investment (for example, equity or convertible
debt)

Identify at least 2 of the start-ups listed above that each created,
subsequent to such investment, at least 5 qualified jobs or
generated at least $500,000 in revenue with average annualized
revenue growth of at least 20 percent.

Company 1
20.

Name of Company

21.

DUNS Number

Qualified Investor Verification
12.

Is the investor a U.S. citizen or lawful permanent resident
of the United States?
Yes
No

13.

Has the investor been permanently or temporarily enjoined
from participating in the offer or sale of a security or in the
provision of services as an investment adviser, broker,
dealer, municipal securities dealer, government securities
broker, government securities dealer, bank, transfer agent
or credit rating agency; barred from association with any
entity involved in the offer or sale of securities or provision
of such services; or otherwise found to have participated in
the offer or sale of securities or provision of such services
in violation of law?
Yes
No

Form I-941 04/24/19

Page 9 of 15

Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)

Apt.

27.a. Street Number
and Name
27.b.

22.a. Street Number
and Name
22.b.

Address and Contact Information

Ste.

Flr.

Apt.

Ste.

27.c. City or Town

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27.d. State

22.c. City or Town
22.d. State

Flr.

22.e. ZIP Code

27.e. ZIP Code

27.f. Province

27.g. Postal Code

22.f. Province

27.h. Country

22.g. Postal Code
22.h. Country

Company 2
23.

24.

Name of Company

DUNS Number

25.a. Street Number
and Name
25.b.

Apt.

Ste.

Flr.

28.

Daytime Telephone Number

29.

Fax Number

30.

Email Address

31.

Website Address

Information on Investment

32.a. Aggregate Amount of Investment

25.c. City or Town
25.d. State

$

25.e. ZIP Code

32.b. Types of Investment (for example, equity or
convertible debt)

25.f. Province
25.g. Postal Code
25.h. Country

Name of Investor (if an organization such as a
Venture Capital Firm, Accelerator or Incubator)
26.a. Legal Entity Name

26.b. Trade Name "DBA" (Doing Business As)

26.c. DUNS Number

Form I-941 04/24/19

Qualified Investor Verification
33.

Is the investor majority owned and controlled, directly
and indirectly, by U.S. citizens or lawful permanent
residents of the United States?
Yes
No

34.

Has the investor been permanently or temporarily enjoined
from participating in the offer or sale of a security or in the
provision of services as an investment adviser, broker,
dealer, municipal securities dealer, government securities
broker, government securities dealer, bank, transfer agent
or credit rating agency; barred from association with any
entity involved in the offer or sale of securities or
provision of such services; or otherwise found to have
participated in the offer or sale of securities or provision of
such services in violation of law?
Yes
No

Page 10 of 15

Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)

43.a. Street Number
and Name

List investments in other start-ups by this investor during the
preceding five years totaling no less than $600,000. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.

43.c. City or Town

35.

Name of Company

43.b.

Apt.

Ste.

43.d. State

Flr.

43.e. ZIP Code

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43.f. Province

43.g. Postal Code

36.

DUNS Number

43.h. Country

37.

Year of Investment

38.

Amount of Investment $

39.

Type of Investment

Address Information
40.a. Street Number
and Name
40.b.

Apt.

Company 2

44.

Name of Company

45.

DUNS Number

46.a. Street Number
and Name
46.b.

Ste.

Apt.

Ste.

Flr.

Flr.

46.c. City or Town

40.c. City or Town

46.d. State

40.d. State

46.e. ZIP Code

40.e. ZIP Code

46.f. Province

40.f. Province

46.g. Postal Code

40.g. Postal Code

46.h. Country

40.h. Country

Identify at least 2 of the start-ups listed above that each created,
subsequent to such investment, at least 5 qualified jobs or
generated at least $500,000 in revenue with average annualized
revenue growth of at least 20 percent.

Company 1
41.

Name of Company

42.

DUNS Number

Form I-941 04/24/19

Page 11 of 15

Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)

Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature

Name of Government Entity Providing Grant/Award

NOTE: Read the Penalties section of the Form I-941
Instructions before completing this part. You must file Form
I-941 while in the United States.

47.

Name of Approving Official

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Applicant's Statement

Address and Contact Information

NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.

48.a. Street Number
and Name

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 8. read to me every
question and instruction on this application and my
answer to every question in

48.b.

Apt.

Ste.

48.c. City or Town
48.d. State

48.e. ZIP Code

48.f. Province
48.g. Postal Code
48.h. Country

49.

Flr.

,

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

2.

At my request, the preparer named in Part 9.,
,

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

Daytime Telephone Number

Applicant's Contact Information

50.

Fax Number

51.

Email Address

52.

Website Address

Information on Grant/Award
53.a. Aggregate of Amount of Grant/Award
$
53.b. Types of Grant/Award

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Applicant's Declaration and 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 furthermore 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 law.

Form I-941 04/24/19

Page 12 of 15

Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:

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.

6.a. Applicant's Signature

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

Apt.

Ste.

Flr.

3.c. City or Town

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1) I reviewed and understood all of the information
contained in, and submitted with, my application; and

Applicant's Signature

Interpreter's Mailing Address

3.d. State
3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

6.b. 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. USCIS
may terminate your parole, granted pursuant to this rule, if you
fail to submit the required information or upon a determination
that your continued presence in the United States no longer
provides a significant public benefit.

Interpreter's Certification

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

,

Provide the following information about the interpreter.

which is the same language specified in Part 7., 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 Full Name

Interpreter's Signature

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

7.a. Interpreter's Signature

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

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

Part 8. Interpreter's Contact Information,
Certification, and Signature

2.

Interpreter's Business or Organization Name (if any)

Form I-941 04/24/19

Page 13 of 15

Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant

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.

Provide the following information about the preparer.

Preparer's Full Name

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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)

NOTE: If applicable, provide the name of your accredited
organization recognized by the Board of Immigration Appeals
(BIA).

Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

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

Province

Ste.

Flr.

3.e. ZIP Code

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 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

3.g. Postal Code
3.h. Country

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

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number

6.

Preparer's Email Address (if any)

Form I-941 04/24/19

Page 14 of 15

5.a. Page Number

Part 10. 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 the start-up entity's name 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.
Name of Start-Up Entity

2.

Start-Up Entity Identification Number

3.d.

5.d.

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1.

3.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

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

6.d.

7.a. Page Number
4.a. Page Number

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

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

4.b. Part Number 4.c. Item Number
7.d.

4.d.

Form I-941 04/24/19

Page 15 of 15