Download:
pdf |
pdfPetition for Nonimmigrant Worker:
H-2A Classification
USCIS
Form I-129H2A
Department of Homeland Security
U.S. Citizenship and Immigration Services
Partial Approval (explain)
Receipt
OMB No. 1615-xxxx
Expires xx/xx/20xx
Action Block
For
USCIS
Use
Only
Class:
No. of Workers:
Job Code:
Validity Dates:
From:
To:
DRAFT
Not for
Production
09/03/2020
Classification Approved
Consulate/POE/PFI Notified
At:
Extension Granted
COS/Extension Granted
► START HERE - Type or print in black ink. Answer all questions fully and accurately. If a question does not apply to you (for
example, if you have never been married and the question asks, “Provide the name of your current spouse”), type or print “N/A”
unless otherwise directed. If your answer to a question which requires a numeric response is zero or none (for example, “How
many children do you have?” or “How many times have you departed the United States?”), type or print “None” unless otherwise
directed.
Part 1. Petitioner Information
If you are an individual or sole proprietor filing this petition, complete Item Numbers 1. - 2. If you are a company or an organization
filing this petition, complete Item Number 3. All petitioners should fill out Item Numbers 4. - 14., as applicable. (If filing as Joint
Employers, including as an association of U.S. agricultural producers, complete these Item Numbers 4. - 14. only for the primary
petitioner and submit additional information on the Joint Employer Supplement for Form I-129H2A.)
1.
Legal Name of Petitioning Individual or Sole Proprietor
Family Name (Last Name)
2.
Date of Birth (mm/dd/yyyy)
3.
Petitioning Company or Organization Name
5.
USCIS Online Account Number
Given Name (First Name)
4.
Middle Name
Trade Name or “Doing Business As” Name
►
6.
Primary U.S. Office Address of Petitioner
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Form I-129H2A Edition 10/02/20
ZIP Code
(USPS ZIP Code Lookup)
Page 1 of 23
Part 1. Petitioner Information (continued)
7.
Is your mailing address different from your Primary U.S. Office Address?
Yes
No
If you answered “Yes” to Item Number 7., provide your mailing address below.
8.
Mailing Address
In Care Of Name
Street Number and Name
City or Town
Province
Apt. Ste. Flr. Number
DRAFT
Not for
Production
09/03/2020
State
Postal Code
ZIP Code
Country
Petitioner's Contact Information
9.
U.S. Daytime Telephone Number
11.
Email Address
10.
U.S. Mobile Telephone Number
13.
Individual Taxpayer Identification Number (ITIN)
Tax Payer Identification Numbers
Provide the following information, as applicable.
12.
Employer Identification Number (EIN)
►
14.
►
U.S. Social Security Number
►
E-Verify Information
15.
Are you a participant in the E-Verify program?
Yes
No
If you answered “Yes” to Item Number 15., provide the information requested in Item Numbers 16. - 17.
16.
Employer's Name as Listed in E-Verify
17.
Employer's E-Verify Company Identification Number or an E-verify Client Company Identification Number
Form I-129H2A Edition 10/02/20
Page 2 of 23
Part 2. Information About This Petition
1.
2.
Basis for Classification (select only one box)
A.
New employment.
B.
Continuation of previously approved employment without change with the same employer.
C.
Change in previously approved employment (provide an explanation in Part 11. Additional Information).
D.
New concurrent employment.
E.
Change of employer for a beneficiary already in the requested classification.
F.
Amended petition (provide an explanation in Part 11. Additional Information).
►
3.
4.
DRAFT
Not for
Production
09/03/2020
If you selected Item F. Amended petition in Item Number 1., provide the receipt number of the petition you seek to amend.
Requested Action (select only one box)
A.
Notify the office in Part 4. so that each beneficiary(ies) can apply for and obtain a visa or be admitted, if eligible.
B.
Change the status and extend the stay of each beneficiary because the beneficiary(ies) is/are now in the United States in
another status (see the Instructions for limitations). This is available only when you select Item A. New employment
in Item Number 1. above.
C.
Extend the stay of each beneficiary because the beneficiary(ies) now hold(s) this status.
D.
Amend the stay of each beneficiary because the beneficiary(ies) now hold(s) this status.
Total number of workers included in this petition. (See Instructions relating to when more than one worker can be included.)
►
Part 3. Beneficiary's Information
Indicate the type of beneficiaries you are requesting in this petition, and list the countries of citizenship for these beneficiaries.
1.
Type of Beneficiaries Requested (Select only one box)
Named Workers
2.
Unnamed Workers
List the countries of citizenship for the workers you are requesting.
If requesting unnamed workers in Item Number 1., proceed to Part 4. Processing Information. However, you must provide the
name and all of the information requested below for each H-2A worker who is in the United States or who is not from a country that
has been designated as a participating country in accordance with 8 CFR 214.2(h)(5)(i)(F)(1). See www.uscis.gov/h-2a for the list of
participating countries. If you are providing information for more than one named beneficiary, complete a separate copy of the
Named Worker Attachment for Form I-129H2A for each additional beneficiary included in this petition.
3.
Is each H-2A worker you plan to hire from a country designated as a participating country in accordance
with 8 CFR 214.2(h)(5)(i)(F)(1)? (See www.uscis.gov/h-2a for the list of H-2A participating countries.)
Yes
No
If you answered “No” to Item Number 3., you must provide the information requested in Item Number 4.
Form I-129H2A Edition 10/02/20
Page 3 of 23
Part 3. Beneficiary's Information (continued)
4.
List each H-2A worker from a non-participating country. If you need more space, use Part 11. Additional Information or
attach an additional sheet of paper.
Family Name (Last Name)
Given Name (First Name)
Middle Name
DRAFT
Not for
Production
09/03/2020
NOTE: If any of the H-2A workers you are requesting are nationals of a country that is not designated as a participating country,
you must also provide evidence showing: (1) that workers with the required skills are not available from among United States
workers or among countries currently on the eligible countries list; (2) whether the beneficiaries have been admitted previously to the
United States in H-2A status; (3) that there is no potential for abuse, fraud, or other harm to the integrity of the H-2A visa programs
through the potential admission of the intended workers; and (4) any other factors that may serve the United States' interest.
Information About the Beneficiary
5.
Beneficiary's Full Name
Family Name (Last Name)
6.
Given Name (First Name)
Provide all other names the beneficiary has used. Include nicknames, aliases, maiden name, and names from all previous marriages.
Family Name (Last Name)
Other Information
7.
Date of Birth (mm/dd/yyyy)
Given Name (First Name)
8.
Gender
Male
10.
Middle Name
Alien Registration Number (A-Number)
Middle Name
9.
►
Female
11.
► A-
U.S. Social Security Number
USCIS Online Account Number
►
12.
City or Town of Birth
13.
Province of Birth
14.
Country of Birth
15.
Country of Citizenship or Nationality
16.
Beneficiary's Foreign Address
Street Number and Name
Apt. Ste. Flr. Number
City or Town
Province
Form I-129H2A Edition 10/02/20
Postal Code
Country
Page 4 of 23
Part 3. Beneficiary's Information (continued)
17.
If the beneficiary is in the United States, complete the following:
Date of Last Arrival
Form I-94 Arrival-Departure Record Number
(mm/dd/yyyy)
►
Passport or Travel Document Number
Date Passport or Travel Document Issued
(mm/dd/yyyy)
Date Passport or Travel Document Expires
(mm/dd/yyyy)
Passport or Travel Document Country of Issuance
Current Nonimmigrant
Status
Date Status Expires or Duration of Status (D/S)
(see Form I-94 Arrival/Departure Document)
DRAFT
Not for
Production
09/03/2020
(mm/dd/yyyy)
Student and Exchange Visitor Information System (SEVIS)
Number
18.
Employment Authorization Document (EAD)
Number
Does the beneficiary have a U.S. residential address?
Yes
No
If you answered “Yes” to Item Number 18., you must provide the beneficiary's U.S. residential address information in Item
Number 19.
19.
Beneficiary's Current U.S. Residential Address (Do not list a P.O. Box unless the beneficiary resides in the Commonwealth of
the Northern Mariana Islands (CNMI).)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
20.
Provide the most recent petition/application receipt number for the beneficiary. If none exists, indicate "None."
►
21.
Have you ever filed an immigrant petition for this beneficiary?
Yes
No
If you answered “Yes” to Item Number 21., identify the classification sought and the receipt number for those petitions in
Part 11. Additional Information.
22.
Have you ever filed a nonimmigrant petition for this beneficiary?
Yes
No
If you answered “Yes” to Item Number 22., identify the classification sought and the receipt number for those petitions in Part
11. Additional Information.
23.
Has this beneficiary ever been denied H-2A classification on any prior petition you filed on behalf of
this beneficiary?
Yes
No
If you answered “Yes” to Item Number 23., identify the receipt number for the petition and the date of the decision in Part 11.
Additional Information.
Form I-129H2A Edition 10/02/20
Page 5 of 23
Part 3. Beneficiary's Information (continued)
24.
List the beneficiary's prior periods of stay in H or L classification in the United States for the last three years. Be sure to only
list those periods in which the beneficiary was actually in the United States in an H or L classification. Do not include periods
in which the beneficiary was in a dependent status, for example, H-4 or L-2 status. If you need more space, use Part 11.
Additional Information or attach an additional sheet of paper.
NOTE: Submit copies of any available Form I-94, Form I-797, and/or other USCIS issued documents noting these periods of
stay in the H or L classification.
Employer's Name
Period of Stay (mm/dd/yyyy)
From
25.
DRAFT
Not for
Production
09/03/2020
Has this beneficiary experienced an interrupted stay associated with their entry in H or L classification?
(See the Instructions for more information on interrupted stays.)
To
Yes
No
If you answered “Yes” to Item Number 25., submit evidence of each entry and each exit as evidence of the interrupted stays.
Part 4. Information About the Beneficiary's Public Benefits
Part 4. only applies to petitions that also seek a change of a beneficiary's status or an extension of a beneficiary's nonimmigrant stay
in the United States. If you are filing this petition without a request for the beneficiary's change of status or extension of stay, you
may skip Part 4.
For the beneficiary named above in Part 3. Beneficiary's Information, provide the requested information and submit documentation
as outlined in the Instructions. For each additional beneficiary, please respond to the questions in a separate copy of the Named
Worker Attachment for Form I-129H2A.
1.
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, the following public benefits? (select all that apply).
Yes, the beneficiary has received or is currently certified to receive the following public benefits: (select all that apply)
Any Federal, State, local or tribal cash assistance for income maintenance
Supplemental Security Income (SSI)
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)
Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.
Federal-funded Medicaid
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.
Form I-129H2A Edition 10/02/20
Page 6 of 23
Part 4. Information About the Beneficiary's Public Benefits (continued)
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
11. Additional Information. Submit evidence as outlined in the Instructions.
A.
Type of Public Benefit
Agency that Granted the Public Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, Date the Beneficiary Will Start Receiving the Benefit
(mm/dd/yyyy)
DRAFT
Not for
Production
09/03/2020
Date Benefit or Coverage Ended or Expires (mm/dd/yyyy)
B.
Type of Public Benefit
Agency that Granted the Public 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 Public Benefit
Agency that Granted the Public 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)
D.
Type of Public Benefit
Agency that Granted the Public 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)
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-129 Instructions.
The beneficiary is enlisted in the 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 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 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.
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.
Form I-129H2A Edition 10/02/20
Page 7 of 23
Part 4. Information About the Beneficiary's Public Benefits (continued)
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): 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 the of age 21
While pregnant or during the 60-day period following the last day of pregnancy
B.
DRAFT
Not for
Production
09/03/2020
to mm/dd/yyyy
Provide the applicable dates mm/dd/yyyy
Part 5. Processing Information
1.
Indicate the U.S. Consulate or U.S. Customs and Border Protection (CBP) inspection facility you would like notified if the
petition will be approved with consular notification (for example, you requested consular notification or a requested extension of
stay or change of status cannot be granted).
A.
Type of Office (select only one box)
U.S. Consulate
B.
2.
CBP Pre-flight Inspection Facility
City Where Office is Located
U.S. Port of Entry
C.
U.S. State or Foreign Country
Does each beneficiary in this petition have a valid passport?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If you answered “No” to Item Number 2., provide an explanation in Part 11. Additional Information.
3.
Are you filing any other petitions with this one?
If you answered “Yes” to Item Number 3., how many?
4.
Have you previously filed any other petitions based on the same temporary labor certification as this petition?
If you answered “Yes” to Item Number 4., provide the previous receipt number(s).
5.
►
Are you filing any applications for dependents with this petition?
If you answered “Yes” to Item Number 5., how many?
6.
►
Is any beneficiary in this petition in removal proceedings?
►
If you answered “Yes” to Item Number 6., list the beneficiary's(ies) name(s) in Part 11. Additional Information.
7.
Has any beneficiary in this petition ever been a J-1 exchange visitor or J-2 dependent of a J-1 exchange visitor?
8.
If you answered “Yes” in Item Number 7., provide the dates the beneficiary(ies) maintained status as a J-1 exchange visitor or J-2
dependent. Also, provide evidence of this status by attaching a copy of either a DS-2019, Certificate of Eligibility for Exchange
Visitor (J-1) Status, a Form IAP-66, or a copy of the passport that includes the J visa stamp. Additionally, if applicable, provide
evidence that the beneficiary(ies) fulfilled the two-year foreign residence requirement or had such residence requirement waived.
Form I-129H2A Edition 10/02/20
Yes
No
Page 8 of 23
Part 5. Processing Information (continued)
9.
Are you requesting substitution of beneficiaries who were approved and/or admitted based on a prior
H-2A petition?
Yes
No
Yes
No
If you answered “Yes” to Item Number 9., provide an explanation in Item Number 10.
10.
Explanation
11.
Does any beneficiary in this petition have ownership interest in the petitioning organization or any joint
employer?
DRAFT
Not for
Production
09/03/2020
If you answered “Yes” to Item Number 11., provide an explanation of the beneficiary's(ies') ownership interests in Item
Number 12.
12.
Explanation
13.
Are you or any joint employer currently debarred by the U.S. Department of Labor (DOL)?
Yes
No
14.
Has the temporary labor certification supporting this petition been revoked by DOL?
Yes
No
15.
To the best of your knowledge, have you or any joint employer ever received a final order of debarment
from DOL in any foreign labor certification program?
Yes
No
16.
If you answered “Yes” to Item Numbers 13., 14., and/or 15., provide an explanation. If you need more space, use Part 11.
Additional Information or attach an additional sheet of paper.
Part 6. Basic Information About the Proposed Employment and Employer
1.
Job Title
3.
Is the employment of a seasonal nature (tied to a certain time of year by an event or pattern and
requiring labor levels far above those necessary for ongoing operations)?
Yes
No
4.
Is the employment of a temporary nature (the need will last no longer than one year)?
Yes
No
5.
Explain your temporary need for the workers' services. If the need is of a seasonal nature, you must establish that it is tied to a
certain time of year by an event or pattern and requires labor levels far above those necessary for ongoing operations. If the
need is of a temporary nature, you must establish that it will last no longer than one year. If you need more space for your
explanation, use Part 11. Additional Information or attach an additional sheet of paper.
Form I-129H2A Edition 10/02/20
2.
Temporary Labor Certification ETA Case Number
Page 9 of 23
Part 6. Basic Information About the Proposed Employment and Employer (continued)
6.
Will the beneficiary(ies) be working at multiple worksites?
Yes
No
If you answered “Yes” to Item Number 6., you must submit a detailed itinerary with the dates and locations where the services
or labor is to be performed.
7.
If you answered “No” to Item Number 6., provide the address where the beneficiary(ies) will work, if different from the
address in Part 1. Provide the name of the person or organization associated with the address, if different from the individual
employer, sole proprietor, or company or organization name listed in Part 1.
Name of Person or Organization
DRAFT
Not for
Production
09/03/2020
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
8.
Will the beneficiary(ies) work for you off-site at another company or organization's location?
Yes
No
9.
Have you or a corporate parent, subsidiary, or affiliate filed an application for permanent labor
certification for this same position?
Yes
No
10.
Are you requesting extension of a previously-approved H-2A petition for a period not to exceed two
weeks based on emergent circumstances?
Yes
No
11.
If you answered yes to Item Number 10., you must provide an explanation and supporting documentation. If you need more
space for your explanation, use Part 11. Additional Information or attach an additional sheet of paper.
12.
Is this a full-time position?
13.
If you answered “No” to Item Number 12., how many hours per week for the position?
14.
Wages (in U.S. dollars): $
15.
Other Compensation (Explain)
16.
Dates of intended employment
►
To (mm/dd/yyyy)
17.
Type of Business
19.
Current Number of Employees in the United States
20.
Gross Annual Income
Form I-129H2A Edition 10/02/20
No
per (Specify hour, week, month, or year)
From (mm/dd/yyyy)
$
Yes
18.
21.
Year Established
►
Net Annual Income
$
Page 10 of 23
Part 7. Petitioner and Employer Obligations
1.
Yes
Did you or do you plan to use a staffing, recruiting, or similar placement service or agent to locate the
H-2A workers that you intend to hire by filing this petition?
No
If you answered “Yes” to Item Number 1., provide the name and address of the service or agent used in Item Numbers 2. and 3. If you
need to include the name and address of more than one service or agent, use the space provided in Part 11. Additional Information.
2.
Name of Service or Agent
3.
Address of Service or Agent
Apt. Ste. Flr. Number
City or Town
State
Province
4.
DRAFT
Not for
Production
09/03/2020
Street Number and Name
Postal Code
ZIP Code
Country
Did any of the H-2A workers that you are requesting pay you or an agent, a job placement fee or other
form of compensation (either direct or indirect) as a condition of the employment, or do they have an
agreement to pay you or the service such fees at a later date?
Yes
No
NOTE: The phrase "fee or other form of compensation" includes, but is not limited to, petition fees, attorney fees, recruitment
costs, and any other fees that are a condition of a beneficiary's employment that the employer is prohibited from passing to the
H-2A worker under law. This phrase does not include reasonable travel expenses and certain government-mandated fees (such
as passport fees) that are not prohibited from being passed to the H-2A worker by statute, regulations, or any laws
5.
If you answered “Yes” to Item Number 4., list the types and amounts of fees that the worker(s) paid or have agreed to pay. If
you need to include information about more than three fees, use the space provided in Part 11. Additional Information.
Type of Fee
Amount
$
$
$
6.
If the workers paid any fee or compensation, were they reimbursed?
Yes
No
Yes
No
Yes
No
If you answered “Yes” to Item Number 6., submit evidence of reimbursement with this petition.
7.
If the workers agreed to pay a fee, was that agreement terminated before the workers paid the fee?
If you answered “Yes” to Item Number 7., submit evidence of termination with this petition.
8.
If you answered “Yes” to Item Number 1., have you made inquiries to determine that the recruiter,
facilitator, agent or similar employment service that you used or plan to use has not collected, and will not
collect, directly or indirectly, any fees or other compensation from the H-2A workers requested in this
petition as a condition of the H-2A workers' employment?
NOTE: If USCIS determines that you knew, or should have known, that the workers requested in connection with this petition paid
any fees or other compensation at any time as a condition of employment, your petition may be denied or revoked.
9.
Have you ever had an H-2A petition denied or revoked because an employee paid a job placement fee or
other similar compensation as a condition of the job offer or employment?
10.
If you answered “Yes” to Item Number 9., when was the petition denied or revoked? (mm/dd/yyyy)
11.
Receipt Number of denied or revoked H-2A petition: ►
Form I-129H2A Edition 10/02/20
Yes
No
Page 11 of 23
Part 7. Petitioner and Employer Obligations (continued)
12.
Describe the types and amounts of fees the workers paid or agreed to pay in connection with the denied or revoked petition. If
you need to include information about more than three fees, use the space provided in Part 11. Additional Information.
Type of Fee
Amount
$
$
$
13.
Were the workers reimbursed for such fees and compensation that they paid in connection with the
denied or revoked petition?
DRAFT
Not for
Production
09/03/2020
Yes
No
If you answered “Yes” to Item Number 13., submit evidence of reimbursement. If you answered “No”
to Item Number 13. because you were unable to locate the workers, include evidence of your efforts to
locate the workers.
14.
The H-2A petitioner and each employer consent to allow DHS access to the site where the labor is being performed for the
purpose of determining compliance with H-2A requirements. The petitioner further agrees to notify DHS within 2 workdays if:
A.
An H-2A worker fails to report for work within 5 workdays after the employment start date stated on the petition or within
5 workdays of the start date established by the petitioner, whichever is later;
B.
The agricultural labor or services for which H-2A workers were hired is completed more than 30 days early;
C.
The H-2A worker absconds from the worksite by failing to report for work for 5 consecutive workdays without the
consent of the employer; or
D.
The H-2A worker is terminated prior to the completion of agricultural labor or services for which he or she was hired.
Yes
No
See www.uscis.gov/h-2a for the appropriate manner of notifying DHS as specified in a notice published in the Federal Register.
NOTE: “Workday” means the period between the time on any particular day when such employee commences his or her
principal activity and the time on that day at which he or she ceases such principal activity or activities.
15.
The petitioner agrees to retain evidence of such notification and make it available for inspection by DHS
officers for a one-year period.
Yes
No
16.
The H-2A petitioner agrees to pay $10 in liquidated damages for each instance where it cannot demonstrate
it is in compliance with the notification requirement.
Yes
No
Petitioner or Employer's Agreement
The petitioner must complete and sign Item Number 17. If the petitioner is the employer's agent, the employer must complete and
sign Item Number 18. If there are joint employers, they must complete the Joint Employer Supplement for Form I-129H2A.
17.
Petitioner
By filing this petition, I agree to the conditions of H-2A employment and agree to the notification requirements. I also agree to
the liquidated damages requirements defined in 8 CFR 214.2(h)(5)(vi)(B)(3)
Name of Petitioner
Signature of Petitioner
Form I-129H2A Edition 10/02/20
Date (mm/dd/yyyy)
Page 12 of 23
Part 7. Petitioner and Employer Obligations (continued)
18.
Employer Who is Not the Petitioner
I certify that I have authorized the party filing this petition to act as my agent in this regard. I assume full responsibility for all
representations made by this agent on my behalf and agree to the conditions of H-2A eligibility.
Name of Employer
Signature of Employer
Date (mm/dd/yyyy)
DRAFT
Not for
Production
09/03/2020
Part 8. Statement, Contact Information, Certification, and Signature of the Petitioner or Authorized
Signatory
NOTE: Read the Penalties section of the Form I-129H2A Instructions before completing this section.
Petitioner's or Authorized Signatory's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.
Petitioner's or Authorized Signatory's Statement Regarding the Interpreter
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.
B.
The interpreter named in Part 9. 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, and I
understood all of this information as interpreted.
2.
Petitioner's or Authorized Signatory's Statement Regarding the Preparer
At my request, the preparer named in Part 10.,
,
prepared this petition for me based only upon information I provided or authorized.
Petitioner's or Authorized Signatory's Declaration and Certification
Copies of any documents submitted are exact photocopies of unaltered, original documents, and I understand that, as the petitioner or
authorized signatory, I may be required to submit original documents to USCIS at a later date.
I authorize the release of any information contained in this petition, in supporting documents, in my USCIS records, and in the
petitioning organization's USCIS 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.
If filing this petition on behalf of an organization, I certify that I am authorized to do so by the organization.
I certify that the petitioner and the employer whose offer of employment formed the basis of status (if different from the petitioner)
will be jointly and severally liable for the reasonable costs of return transportation of the beneficiary abroad if the beneficiary is
dismissed from employment by the employer before the end of the period of authorized stay.
I certify, under penalty of perjury, that all of the information in my petition 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 petition and that all of
this information is complete, true, and correct.
Form I-129H2A Edition 10/02/20
Page 13 of 23
Part 8. Statement, Contact Information, Certification, and Signature of the Petitioner or Authorized
Signatory (continued)
I certify, under penalty of perjury, that all of the information in my petition 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 petition and that all of
this information is complete, true, and correct.
Petitioner's or Authorized Signatory's Signature
3.
Petitioner's or Authorized Signatory's Signature
Date of Signature (mm/dd/yyyy)
DRAFT
Not for
Production
09/03/2020
If Part 8. is being completed by an Authorized Signatory, provide the name and title of the Authorized Signatory.
Name and Title of Authorized Signatory
4.
Family Name (Last Name)
5.
Title
Given Name (First Name)
Authorized Signatory's Contact Information
6.
Daytime Telephone Number
8.
Email Address (if any)
7.
Mobile Telephone Number (if any)
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 deny your petition.
Part 9. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Full Name
1.
Interpreter's Family Name (Last Name)
2.
Interpreter's Business or Organization Name (if any)
Form I-129H2A Edition 10/02/20
Interpreter's Given Name (First Name)
Page 14 of 23
Part 9. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
Postal Code
ZIP Code
Country
DRAFT
Not for
Production
09/03/2020
Interpreter's Contact Information
4.
Interpreter's Daytime Telephone Number
6.
Interpreter's Email Address (if any)
5.
Interpreter's Mobile Telephone Number (if any)
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
which is the same language specified in Part 8.,
Item B. in Item Number 1., 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
Certification, and has verified the accuracy of every answer.
Interpreter's Signature
7.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Petition, if Other
Than the Petitioner or Authorized Signatory
Provide the following information about the preparer.
Preparer's Full Name
1.
Preparer's Family Name (Last Name)
2.
Preparer's Business or Organization Name (if any)
Form I-129H2A Edition 10/02/20
Preparer's Given Name (First Name)
Page 15 of 23
Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Petition, if Other
Than the Petitioner or Authorized Signatory (continued)
Preparer's Mailing Address
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
ZIP Code
DRAFT
Not for
Production
09/03/2020
Postal Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
6.
Preparer's Email Address (if any)
5.
Preparer's Mobile Telephone Number (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 or authorized signatory's consent.
B.
I am an attorney or accredited representative and my representation of the petitioner or authorized signatory 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.
Preparer's Certification
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 or authorized signatory has reviewed this completed petition, including the Petitioner's or Authorized Signatory's
Certification, and informed me that all of the information in the petition and in the supporting documents is complete, true, and correct.
Preparer's Signature
8.
Preparer's Signature
Form I-129H2A Edition 10/02/20
Date of Signature (mm/dd/yyyy)
Page 16 of 23
Part 11. Additional Information
If you require more space to provide any additional information within this petition, use the space below. If you require more space
than what is provided to complete this petition, you may make a copy of Part 11. to complete and file with this petition. In order to
assist us in reviewing your response, you must identify the Number, Part Number, and Item Number corresponding to the
additional information.
1.
Individual Petitioner or Company Name (same as Part 1.)
Family Name (Last Name)
2.
A.
D.
3.
A.
D.
4.
A.
D.
5.
A.
Given Name (First Name)
Middle Name
DRAFT
Not for
Production
09/03/2020
Page Number
B. Part Number
C. Item Number
Page Number
B. Part Number
C. Item Number
Page Number
B. Part Number
C. Item Number
Page Number
B. Part Number
C. Item Number
Page Number
B. Part Number
C. Item Number
D.
6.
A.
D.
Form I-129H2A Edition 10/02/20
Page 17 of 23
Named Worker Attachment for Form I-129H2A
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-129H2A
OMB No. 1615-xxxx
Expires xx/xx/20xx
Attach to Form I-129H2A when more than one person is included in the petition. A single H-2A petition may be filed on behalf of no
more than 25 named workers. Therefore, do not include more than 24 Named Worker Attachments with a single I-129H2A petition.
Complete a separate copy of this attachment for each additional beneficiary included in this petition. (Do not complete a copy of this
Attachment for the beneficiary you already named in Part 3. of Form I-129H2A.)
Petitioner's Information
DRAFT
Not for
Production
09/03/2020
Provide the same petitioner name information that was provided in Part 1. of Form I-129H2A, as applicable.
1.
Legal Name of Petitioning Individual or Sole Proprietor
Family Name (Last Name)
2.
Given Name (First Name)
Middle Name
Given Name (First Name)
Middle Name
Petitioning Company or Organization Name
Beneficiary's Information
3.
Beneficiary Full Name
Family Name (Last Name)
4.
Provide all other names the beneficiary has used. Include nicknames, aliases, maiden name, and names from all previous
marriages.
Family Name (Last Name)
Other Information
5.
Date of Birth (mm/dd/yyyy)
Given Name (First Name)
6.
Gender
Male
8.
Alien Registration Number (A-Number)
►
7.
U.S. Social Security Number
►
Female
9.
Middle Name
USCIS Online Account Number
►
A-
10.
City or Town of Birth
11.
Province of Birth
12.
Country of Birth
13.
Country of Citizenship or Nationality
Form I-129H2A Edition 10/02/20
Page 18 of 23
14.
Beneficiary's Foreign Address
Street Number and Name
Apt. Ste. Flr. Number
City or Town
Province
15.
Postal Code
Country
If the beneficiary is in the United States, complete the following:
DRAFT
Not for
Production
09/03/2020
Date of Last Arrival
Form I-94 Arrival-Departure Record Number
(mm/dd/yyyy)
►
Passport or Travel Document Number
Date Passport or Travel Document Issued
(mm/dd/yyyy)
Date Passport or Travel Document Expires
(mm/dd/yyyy)
Passport or Travel Document Country of Issuance
Current Nonimmigrant
Status
Date Status Expires or Duration of Status (D/S)
(see Form I-94 Arrival/Departure Document)
(mm/dd/yyyy)
Student and Exchange Visitor Information System (SEVIS)
Number
16.
Employment Authorization Document (EAD)
Number
Does the beneficiary have a U.S. residential address?
Yes
No
If you answered “Yes” to Item Number 16., you must provide the beneficiary's U.S. residential address information in Item
Number 17.
17.
18.
Beneficiary's Current U.S. Residential Address (Do not list a P.O. Box unless the beneficiary resides in the Commonwealth of
the Northern Mariana Islands (CNMI).)
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
Provide the most recent petition/application receipt number for the beneficiary. If none exists, indicate "None."
►
19.
Have you ever filed an immigrant petition for this beneficiary?
Yes
No
If you answered "Yes" to Item Number 19., identify the classification sought and the receipt number for those petitions in
Part 11. Additional Information.
20.
Have you ever filed a nonimmigrant petition for this beneficiary?
Yes
No
If you answered "Yes" to Item Number 20., identify the classification sought and the receipt number for those petitions in
Part 11. Additional Information.
21.
Has this beneficiary ever been denied H-2A classification on any prior petition you filed on behalf of
this beneficiary?
Yes
No
If you answered "Yes" to Item Number 21., identify the classification sought and the receipt number for those petitions in
Part 11. Additional Information.
Form I-129H2A Edition 10/02/20
Page 19 of 23
22.
List the beneficiary's prior periods of stay in H or L classification in the United States for the last three years. Be sure to only
list those periods in which the beneficiary was physically present in the United States in an H or L classification. Do not include
periods in which the beneficiary was in a dependent status, for example, H-4 or L-2 status. If you need more space, use Part 11.
Additional Information or attach an additional sheet of paper.
NOTE: Submit copies of any available Forms I-94, I-797, and/or other USCIS issued documents noting these periods of stay in
the H or L classification.
Employer's Name
Period of Stay (mm/dd/yyyy)
From
23.
DRAFT
Not for
Production
09/03/2020
Has this beneficiary experienced an interrupted stay associated with their entry in H or L
classification? (See form Instructions for more information on interrupted stays.)
To
Yes
No
If you answered “Yes” to Item Number 23., submit evidence of each entry and each exit as evidence of the interrupted stays.
Information About the Additional Beneficiary's Public Benefits
Item Numbers 24. - 27.B. only apply to petitions that also seek a change of a beneficiary's status or an extension of a beneficiary's
nonimmigrant stay in the United States. If you are filing this petition without a request for the beneficiary's change of status or
extension of stay, you may skip Item Numbers 24. - 27.B.
24.
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).
Yes, the beneficiary has received or is currently certified to receive the following public benefits:
Any Federal, State, local or tribal cash assistance for income maintenance
Supplemental Security Income (SSI)
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)
Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.
Federal-funded Medicaid
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.
25.
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 11.
Additional Information. Submit evidence as outlined in the Instructions.
A.
Type of Public Benefit
Agency that Granted the Public 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-129H2A Edition 10/02/20
Page 20 of 23
B.
Type of Public Benefit
Agency that Granted the Public 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 Public Benefit
Agency that Granted the Public Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, Date the Beneficiary Will Start Receiving the Benefit
DRAFT
Not for
Production
09/03/2020
(mm/dd/yyyy)
Date Benefit or Coverage Ended or Expires (mm/dd/yyyy)
D.
Type of Public Benefit
Agency that Granted the Public 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)
26.
If you answered “Yes” to Item Number 24., do any of the following apply to the beneficiary? Provide the evidence listed in the
Form I-129 Instructions.
The beneficiary is enlisted in the 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 Armed Forces, or 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 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.
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.
27.
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): 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 the of age 21
While pregnant or during the 60-day period following the last day of pregnancy
B.
Provide the applicable dates (mm/dd/yyyy)
Form I-129H2A Edition 10/02/20
to (mm/dd/yyyy)
Page 21 of 23
USCIS
Form I-129H2A
Joint Employer Supplement for Form I-129H2A
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-xxxx
Expires xx/xx/20xx
If you are an individual joint employer, complete Item Numbers 1. - 2. Provide a company or an organization name in Item Number
3. All joint employers should fill out Item Numbers 4. - 16.
1.
Legal Name of Individual Joint Employer
Family Name (Last Name)
Given Name (First Name)
DRAFT
Not for
Production
09/03/2020
2.
Individual Joint Employer's Date of Birth (mm/dd/yyyy)
3.
Petitioning Company or Organization Name
4.
Mailing Address of Individual, Company or Organization
In Care Of Name
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
Province
5.
Middle Name
Postal Code
ZIP Code
Country
Contact Information
Daytime Telephone Number
Email Address
Mobile Telephone Number
Tax Payer Identification Numbers
Provide the following information, as applicable.
6.
Employer Identification Number (EIN)
7.
►
8.
Individual Taxpayer Identification Number (ITIN)
►
U.S. Social Security Number
►
Other Information
9.
Type of Business
11.
Current Number of Employees in the United States
Form I-129H2A Edition 10/02/20
10.
Year Established
►
Page 22 of 23
12.
Gross Annual Income
13.
$
Net Annual Income
$
E-Verify Information
14.
Are you a participant in the E-Verify program?
Yes
No
If you answered “Yes” to Item Number 14., provide the information requested in Item Numbers 15. - 16.
15.
Employer's Name as Listed in E-Verify
16.
Employer's E-Verify Company Identification Number or an E-Verify Client Company Identification Number
DRAFT
Not for
Production
09/03/2020
Joint Employer's Certification
I agree to the conditions of H-2A eligibility.
Name and Title of Authorized Signatory
17.
Family Name (Last Name)
18.
Title
19.
Signature of Authorized Signatory
Form I-129H2A Edition 10/02/20
Given Name (First Name)
Date of Signature (mm/dd/yyyy)
Page 23 of 23
| File Type | application/pdf |
| File Title | I-129H2A, Petition for Nonimmigrant Worker: H-2A Classification |
| Author | USCIS |
| File Modified | 2020-09-03 |
| File Created | 2020-09-03 |