Page 1, Part 1. Basis
for Your Request (Each
basis is further explained in the Specific
Instructions section
of the Form I-219 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.
[ ] 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.)
[ ] My household income is at
or below 150 percent of the Federal Poverty Guidelines.
(Complete Parts 2. - 3., Part 5., and 7.
- 10.)
[ ] I have a financial
hardship. (Complete Parts 2. -3. and Parts 6.
- 10.
[new]
|
[Page 1]
[no change]
1.
Select a basis for which you may
qualify and provide supporting documentation for any basis you
select.
[delete]
[]
A. My annual
household income is at or below 125
percent of the Federal Poverty Guidelines and
I am applying for, have status as, or have been approved as one of
the following:
[delete]
[] A battered
spouse or child of a lawful permanent resident or U.S. citizen or
derivative of such individual under INA 240A(b)(2)
[] A T
nonimmigrant
[] A U
nonimmigrant
[] A VAWA
self–petitioner or his or her derivative
[] Temporary
Protected Status (TPS)
[] A Special
Immigrant Juvenile (SIJ), and I am currently placed in out-of-home
care under the supervision of a juvenile court or a state child
welfare agency
[]
Applicant as an Afghan or Iraqi Translator
or Interpreter, Iraqi National employed by or on behalf of the
U.S. Government, or Afghan National employed by or on behalf of
the U.S. government or employed by the International Security
Assistance Forces.
Provide the
Receipt Number for the category you indicated in Item
Number 1.A.
[] B.
I am impacted by an emergent
circumstance or major natural disaster declaration posted to
www.uscis.gov providing relief from USCIS filing fees and my
documented
annual household income is at or below 125 percent of the Federal
Poverty Guidelines (FPG), and I am not seeking an immigration
benefit for which I would be subject to the public charge ground
of inadmissibility, the affidavit of support requirement under INA
212(a)(4)(C) or (D), and I am not already a sponsored immigrant as
defined by 8 CFR 213a.1.
2. What
is your current immigrant or nonimmigrant status?
3.
For what application(s) or
petition(s) are you applying for a fee waiver?
[Table: 6
Fields]
|
Page 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.
Full Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other Names Used (if any)
List all other names you have
used, including nicknames, aliases, and maiden name.
Family Name (Last Name)
Given Name (First Name)
Middle Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
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)
|
[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.
Full Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
Other Names Used
List all other names you have
used, including nicknames, aliases, and maiden name.
Family Name (Last Name)
Given Name (First Name)
Middle Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
Alien Registration Number
(A-Number)
4. USCIS Online Account
Number
5. Date of Birth
(mm/dd/yyyy)
6. U.S. Social Security Number
[Page 2]
7. Marital Status
[ ] Single, Never Married
[ ] Married
[ ] Divorced
[ ] Widowed
[ ] Marriage Annulled
[ ] Separated
[ ] Other (Explain)
|
Page 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?
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?
A. If you answered “No”
to Item Number 3., does your spouse provide any financial
support to your household?
Your Household Size
4. Are you the person
providing the primary financial support for your household?
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
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.
[new]
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.
[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]
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.)
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.
[new]
|
[Page 2]
Part 3.
Household Gross Income
For
information regarding required documentation, see the
instructions.
If
you are an SIJ placed in out-of-home care under the supervision of
a juvenile court or state child welfare agency, you do not need to
complete Part 3.
[no change]
Information About Your Spouse
3. If you are married
(including separated, but not divorced), does your spouse
live in your household?
Yes (add your
spouse to the table below and provide his or her gross income in
Item Number 7.
below)
No
N/A
- not married
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 8. below)
No
Your Household Size
4.
Are you the person providing the primary financial support (head
of household) 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 and
also provide your gross income in Item
Number 6. 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]
[Table: Household Gross
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 Gross Household
Income
[moved down]
5. Did
you file a federal tax return in the last year?
Yes
No
If you
answered “No” to Item
Number 5., provide an answer to
Item C.
A.
Did any of your household members file a tax return for the last
year?
Yes
No
If you
answered “No” to Item
A., provide an answer to Item
B. and
C.
B.
If no, which household member(s) did not file a tax return?
C.
If you or your household member(s) did not file a tax return,
select the reason for not filing and provide an explanation.
I/we plan to
file the tax return before the due date this year
I/we are not
required to file a tax return
I/we filed for
an extension
I/we are not
going to file
Explanation:
Provide
information about your gross income and the income of all family
members counted as part of your household. You must list all
amounts in U.S. dollars.
6.
Your Annual Gross Income
7.
Annual Gross Income of All
Family Members Counted as Part of Your
Household (Do not include the amount provided in Item
Number 6.)
[deleted]
8.
Total Additional Income or Financial Support (Do
not include the amount provided in Item
Number 6. or
7.)
If you
received additional income on a continuing basis (e.g., monthly or
annually) 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
Stipend, Yes/No
Royalties, Yes/No
Pension,
Yes/No
Unemployment Benefit,
Yes/No
Social Security Benefit,
Yes/No
Veteran's Benefit,
Yes/No
Financial
Support from Adult Child(ren),
Dependent, Other Person Living
in the Household, Yes/No
Other, Yes/No, Explanation]
[Page 4]
9.
Total Annual Gross Household
Income (add the amounts from Item Numbers 6.,
7., and 8.)
10.
Has any information you reported in the last
income tax return changed since the date you filed your
Federal income tax return?
(For example, your marital status, income, or number of
dependents.) Yes No
If you answered "Yes" to
Item Number 10.,
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.
11. If
you already have or are applying for VAWA benefits or T or U
nonimmigrant status, are you unable to obtain documentation of
your income or a household member’s income?
Yes
No
If
you answered “Yes” to Item
Number 11., provide an
explanation below explaining your inability to obtain the required
documentation. Provide any other available documentation of your
and your household’s income. 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.
|
Page 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 in the spaces below. You
can find additional family members’ signature spaces in Item
Numbers7.-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 5]
Part
4. Requestor's Statement, Contact Information,
Certification, and Signature
[no change]
[deleted]
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 5. 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 6.,
[fillable field] ,
prepared this request for me based only upon information I
provided or authorized.
[no change]
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 reject or deny
your request.
[deleted]
|
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.
|
[deleted]
|
Page 8, Part 9.
Interpreter’s Contact Information, Certification, and
Signature
|
[Page 8]
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.
|
[deleted]
|
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.)?
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
(USPS ZIP Code Lookup)
5. Street Number and Name
Apt Ste Flr
City or Town
State
ZIP Code
Province
Postal Code
Interpreter's Contact
Information Country
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 8]
Part
5. Interpreter's
Contact Information, Certification, and Signature
[deleted]
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
(USPS ZIP Code Lookup)
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 4.,
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)
|
Page 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
2. Was the same preparer
used for all individuals requesting a fee waiver (as listed in
Part 3.)?
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
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 request.
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 9]
Part
6. Contact
Information, Declaration, and Signature of the Person Preparing
this Request, if Other Than the Requestor
[deleted]
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)
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 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.
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)
|