TABLE OF CHANGES – FORM
Form I-485 Supplement J, Confirmation of Bona Fide Job Offer or Request for Job Portability Under INA Section 204(j)
OMB Number: 1615-0023
11/12/2020
Reason for Revision: Revision Project Phase: OMB Review
Legend for Proposed Text:
Expires 10/31/2020 Edition Date 10/15/2019 |
Current Page Number and Section |
Current Text |
Proposed Text |
Page 1, Part 1. Reason for Filing Supplement J |
[Page 1]
NOTE: Use Form I-485, Supplement J, Confirmation of Bona Fide Job Offer or Request for Job Portability Under INA Section 204(j) (Supplement J), to either confirm that the job offered to you in Form I-140, Immigrant Petition for Alien Worker, that is the basis of your Form I-485, Application to Register Permanent Residence or Adjust Status, remains available to you or to request job portability under the Immigration and Nationality Act (INA) section 204(j).
START HERE - Type or print in black ink.
[New]
Part 1. Reason for Filing Supplement J
This supplement is being filed to (Select only one box):
1.a. Confirm that the job offered to you in the Form I-140, that is the basis of your Form I-485, remains a bona fide job offer that you intend to accept once your Form I-485 is approved.
1.b. Request job portability under INA section 204(j) to a new, full-time, permanent job offer that you intend to accept once your Form I-485 is approved.
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[Page 1]
Use Form I-485, Supplement J, Confirmation of Bona Fide Job Offer or Request for Job Portability Under INA Section 204(j) (Supplement J), to either confirm that the job offered to you in Form I-140, Immigrant Petition for Alien Worker, that is the basis of your Form I-485, Application to Register Permanent Residence or Adjust Status, remains available to you or to request job portability under the Immigration and Nationality Act (INA) section 204(j).
START HERE - Type or print in black ink.
NOTE TO ALL APPLICANTS: If you leave any fields blank on this form or fail to submit required documents listed in the Instructions, U.S. Citizenship and Immigration Services (USCIS) may reject or deny your application.
IMPORTANT: The applicant completes Parts 1., 2., and 3.
Part 1. Reason for Filing Supplement J
This supplement is being filed to (Select only one box):
1.a. Confirm that the job offered to you in the Form I-140, that is the basis of your Form I-485, remains a bona fide job offer that you intend to accept once your Form I-485 is approved.
1.b. Request job portability under INA section 204(j) to a new, full-time, permanent job offer that you intend to accept once your Form I-485 is approved.
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Page 1, Part 2. Information About You (Applicant) |
[Page 1]
Part 2. Information About You (Applicant)
Your Current Legal Name (do not provide a nickname) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name
U.S. Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Fillable field] 2.d. City or Town 2.e. State 2.f. ZIP Code
Other Information 3. Alien Registration Number (A-Number) 4. USCIS Online Account Number 5. Date of Birth (mm/dd/yyyy) 6. Country of Birth
Basic Information About Your Form I-485 and the Underlying Form I-140 7. Form I-485 Receipt Number (if already filed with U.S. Citizenship and Immigration Services (USCIS)) 8. Form I-485 Filing Date (mm/dd/yyyy) (if already filed with USCIS) 9. Form I-140 Receipt Number
10. Has your Form I-140 been approved? Yes No Unknown
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[Page 1]
Part 2. Information About You (Applicant)
Your Current Legal Name (do not provide a nickname) 1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name
U.S. Mailing Address 2.a. In Care Of Name 2.b. Street Number and Name 2.c. Apt./Ste./Flr. [Fillable field] 2.d. City or Town 2.e. State 2.f. ZIP Code
Other Information 3. Alien Registration Number (A-Number) 4. USCIS Online Account Number 5. Date of Birth (mm/dd/yyyy) 6. Country of Birth
Basic Information About Your Form I-485 and the Underlying Form I-140 7. Form I-485 Receipt Number (if already filed with U.S. Citizenship and Immigration Services (USCIS)) 8. Form I-485 Filing Date (mm/dd/yyyy) (if already filed with USCIS) 9. Form I-140 Receipt Number
10. Has your Form I-140 been approved? Yes No Unknown
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Page 2, Part 3. Applicant's Statement, Contact Information, Certification, and Signature |
[Page 2]
Part 3. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Supplement J Instructions before completing this part. You must file Supplement J while in the United States.
Applicant's Statement
Select all applicable boxes.
1. I can read and understand English, and I have read and understand every question and instruction on this supplement and my answer to every question.
2. At my request, the preparer named in Part 4., [Fillable field], prepared this supplement for me based only upon information I provided or authorized.
Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any)
Applicant'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 supplement, in supporting documents, and in my USCIS records to other entities and persons when 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 supplement, especially in Part 1. and Part 2., I understand all of the information contained in, and submitted with my supplement, and that all of this information is complete, true, and correct.
I further declare, under penalty of perjury, that I have reviewed the job offer described in Part 6. of this supplement, and I intend to accept the position offered in Part 6. of this supplement upon approval of my Form I-485.
Applicant's Signature 6.a. Applicant's Signature (sign in ink) 6.b. Date of Signature (mm/dd/yyyy)
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[Page 2]
Part 3. Applicant's Statement, Contact Information, Certification, and Signature
Read the Penalties section of the Supplement J Instructions before completing this part. You must file Supplement J while in the United States.
Applicant's Statement
Select all applicable boxes.
1. I can read and understand English, and I have read and understand every question and instruction on this supplement and my answer to every question.
2. At my request, the preparer named in Part 4., [Fillable field], prepared this supplement for me based only upon information I provided or authorized.
Applicant's Contact Information 3. Applicant's Daytime Telephone Number 4. Applicant's Mobile Telephone Number (if any) 5. Applicant's Email Address (if any)
Applicant's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records to other entities and persons when necessary for the administration and enforcement of any U.S. law.
I certify, under penalty of perjury, that I provided or authorized all of the information in my supplement. I understand all of the information contained in, and submitted with my supplement, and that all of this information is complete, true, and correct.
I further declare, under penalty of perjury, that I have reviewed the job offer described in Part 6. of this supplement, and I intend to accept the position offered in Part 6. of this supplement upon approval of my Form I-485.
Applicant's Signature 6.a. Applicant's Signature (sign in ink) 6.b. Date of Signature (mm/dd/yyyy)
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Page 2, Part 4. Contact Information, Declaration, and Signature of the Person Preparing This Supplement, if Other Than the Applicant |
[Page 2]
Part 4. Contact Information, Declaration, and Signature of the Person Preparing This Supplement, if Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any)
Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. 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)
[Page 3]
Preparer's Statement 7.a. I am not an attorney or accredited representative but have prepared this supplement 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 supplement.
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, with this supplement.
Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this supplement at the request of the applicant. The applicant then reviewed this completed supplement and informed me that he or she understands all of the information contained in, and submitted with, his or her supplement, including the Applicant's Certification, and that all of this information is complete, true, and correct.
Preparer's Signature 8.a. Preparer's Signature (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)
IMPORTANT: The employer confirming an existing bona fide job offer or offering you a new, permanent job must complete Parts 5., 6., and 7.
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[Page 2]
Part 4. Contact Information, Declaration, and Signature of the Person Preparing Parts 1. - 4. of This Supplement, if Other Than the Applicant
Provide the following information about the preparer if you used one.
Preparer's Full Name 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any)
Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. 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)
[Page 3]
Preparer's Statement 7.a. I am not an attorney or accredited representative but have prepared this supplement 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 supplement.
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, with this supplement.
Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared Parts 1. - 4. of this supplement at the request of the applicant. The applicant then reviewed this completed supplement and informed me that he or she understands all of the information contained in, and submitted with, his or her supplement, including the Applicant's Certification, and that all of this information is complete, true, and correct. I completed this supplement 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 (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)
IMPORTANT: The employer confirming an existing bona fide job offer or offering the applicant a new, permanent job must complete Parts 5., 6., and 7.
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Page 3, Part 5. Information About the Employer |
[Page 3]
Part 5. Information About the Employer
1. Type of employer (Select only one box): Business/Organization Self/Individual
Employer's U.S. Mailing Address 2.a. Street Number and Name 2.b. Apt./Ste./Flr. [Fillable field] 2.c. City or Town 2.d. State 2.e. ZIP Code
[New]
Information About the Business Entity Employer
If you, the employer, are a business entity, provide the information requested in Item Numbers 3. - 10.
3. Business or Organization Name 4. Employer Identification Number 5. Type of Business 6. Date Established (mm/dd/yyyy) 7. Current Number of U.S. Employees 8. Gross Annual Income 9. Net Annual Income 10. NAICS Code
Information About the Individual Employer
Your Current Legal Name (do not provide a nickname) 11.a. Family Name (Last Name) 11.b. Given Name (First Name) 11.c. Middle Name
12. Date of Birth (mm/dd/yyyy) 13. U.S. Social Security Number 14. Annual Income 15. Occupation
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[Page 3]
Part 5. Information About the Employer
1. Type of employer (Select only one box): Business/Organization Self/Individual
Employer's U.S. Mailing Address 2.a. Street Number and Name 2.b. Apt./Ste./Flr. [Fillable field] 2.c. City or Town 2.d. State 2.e. ZIP Code
Employer's U.S. Physical Address
Provide the physical address where the applicant will work if different from the employer's mailing address in Item Numbers 2.a. - 2.e. or the address provided in Form I-140 on which the applicant's Form I-485 is based.
3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State
Information About the Business Entity Employer
If you, the employer, are a business entity, provide the information requested in Item Numbers 4. - 11.
4. Business or Organization Name 5. Employer Identification Number 6. Type of Business 7. Date Established (mm/dd/yyyy) 8. Current Number of U.S. Employees 9. Gross Annual Income 10. Net Annual Income
[Page 4]
Information About the Individual Employer
Your Current Legal Name (do not provide a nickname) 12.a. Family Name (Last Name) 12.b. Given Name (First Name) 12.c. Middle Name
13. Date of Birth (mm/dd/yyyy) 14. U.S. Social Security Number 15. Annual Income
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Page 4, Part 6. Information About the Job Offer |
[Page 4]
Part 6. Information About the Job Offer
You, the employer, must provide the information requested in Part 6.
1. Job Title
2. Standard Occupational Classification (SOC) Code
3. Nontechnical Description of Job (If you need extra space to complete this section, use the space provided in Part 9. Additional Information.) [Fillable field]
4. Is this a full-time position? Yes No
5. If you answered "No" to Item Number 4., provide the number of hours per week the applicant will work in this position.
6. Is this a permanent position? Yes No
7. Wages Offered (Specify hour, week, month, or year) [Fillable field (dollars)] per [Fillable field (unit of time)]
Employer's U.S. Physical Address
Provide the physical address where the applicant will work if different from the employer's mailing address in Part 5., Item Numbers 2.a. - 2.e. or the address provided in Form I-140 on which the applicant's Form I-485 is based.
8.a. Street Number and Name 8.b. Apt./Ste./Flr. [Fillable field] 8.c. City or Town 8.d. State 8.e. ZIP Code
9. Is the applicant named in Part 2. of this supplement currently employed by you? Yes No
10. If you answered "Yes" to Item Number 9., when did the applicant begin employment with you (mm/dd/yyyy)?
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[Page 4]
Part 6. Information About the Job Offer
You, the employer, must provide the information requested in Part 6.
1. Job Title
2. Standard Occupational Classification (SOC) Code
3. Nontechnical Description of Job (If you need extra space to complete this section, use the space provided in Part 9. Additional Information.) [Fillable field]
4. Is this a full-time position? Yes No
5. If you answered “No,” provide the number of hours per week the applicant will work in this position.
6. Is this a permanent position? Yes No
7. Wages Offered (Specify hour, week, month, or year) [Fillable field (dollars)] per [Fillable field (unit of time)]
[moved up to previous Part]
8. Is the applicant named in Part 2. of this supplement currently employed by you? Yes No
9. If you answered “Yes,” when did the applicant begin employment with you (mm/dd/yyyy)? If you answered “No,” write “N/A.”
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Page 4, Part 7. Statement, Contact Information, Certification, and Signature of the Individual Employer or Authorized Signatory of the Business Entity Employer |
[Page 4]
Part 7. Statement, Contact Information, Certification, and Signature of the Individual Employer or Authorized Signatory of the Business Entity Employer
NOTE: Read the Penalties section of the Supplement J Instructions before completing this part.
Individual Employer's or Authorized Signatory's Statement
Select all applicable boxes.
1. I can read and understand English, and I have read and understand every question and instruction on this supplement and my answer to every question.
2. At my request, the preparer named in Part 8., [Fillable field], prepared this supplement for me based only upon information I provided or authorized.
Individual Employer's or Authorized Signatory's Contact Information 3.a. Individual Employer's or Authorized Signatory's Family Name (Last Name) 3.b. Individual Employer's or Authorized Signatory's Given Name (First Name) 4. Individual Employer's or Authorized Signatory's Title
5. Individual Employer's or Authorized Signatory's Daytime Telephone Number 6. Individual Employer's or Authorized Signatory's Mobile Telephone Number (if any) 7. Individual Employer's or Authorized Signatory's Email Address (if any)
[Page 5]
Individual Employer's or Authorized Signatory's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that, as the employer, USCIS may require that I submit original documents to USCIS at a later date.
I authorize the release of any information from any records of the employer that USCIS may need to determine eligibility for the requested immigration benefit. I recognize the authority of USCIS to conduct audits of this supplement using publicly available open source information. I also recognize that USCIS may verify any supporting evidence submitted in support of this supplement through any means determined appropriate by USCIS, including but not limited to, on-site compliance reviews.
If filling this supplement on behalf of an organization, I certify that I am authorized to do so by the organization.
I certify, under penalty of perjury, that I have reviewed this supplement, and that all of the information contained in Part 5. and Part 6. of this supplement, including all responses provided by me to specific questions and in the supporting documents provided by me, is complete, true, and correct.
I further declare, under penalty of perjury, and attest to the following:
1) I am a viable employer and I am extending a bona fide job offer to the applicant named in Part 2. of this supplement;
2) The job opportunity is for full-time, permanent employment; and
3) I intend to employ the applicant in the job offer described in Part 6. of this supplement upon the approval of the applicant's Form I-485.
Individual Employer's or Authorized Signatory's Signature 8.a. Signature of Individual Employer or Authorized Signatory (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)
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[Page 4]
Part 7. Statement, Contact Information, Certification, and Signature of the Individual Employer or Authorized Signatory of the Business Entity Employer
NOTE: Read the Penalties section of the Supplement J Instructions before completing this part.
Individual Employer's or Authorized Signatory's Statement
Select all applicable boxes.
1. I can read and understand English, and I have read and understand every question and instruction on this supplement and my answer to every question.
2. At my request, the preparer named in Part 8., [Fillable field], prepared this supplement for me based only upon information I provided or authorized.
Individual Employer's or Authorized Signatory's Contact Information 3.a. Individual Employer's or Authorized Signatory's Family Name (Last Name) 3.b. Individual Employer's or Authorized Signatory's Given Name (First Name) 4. Individual Employer's or Authorized Signatory's Title
[Page 5]
5. Individual Employer's or Authorized Signatory's Daytime Telephone Number 6. Individual Employer's or Authorized Signatory's Mobile Telephone Number (if any) 7. Individual Employer's or Authorized Signatory's Email Address (if any)
Individual Employer's or Authorized Signatory's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that, as the employer, USCIS may require that I submit original documents to USCIS at a later date.
I authorize the release of any information from any records of the employer that USCIS may need to determine eligibility for the requested immigration benefit. I recognize the authority of USCIS to conduct audits of this supplement using publicly available open source information. I also recognize that USCIS may verify any supporting evidence submitted in support of this supplement through any means determined appropriate by USCIS, including but not limited to, on-site compliance reviews.
If filling this supplement on behalf of an organization, I certify that I am authorized to do so by the organization.
I certify, under penalty of perjury, that I have reviewed this supplement, and that all of the information contained in Part 5. - Part 7. of this supplement, including all responses provided by me to specific questions and in the supporting documents provided by me, is complete, true, and correct.
I further declare, under penalty of perjury, and attest to the following:
1) I am a viable employer and I am extending a bona fide job offer to the applicant named in Part 2. of this supplement;
2) The job opportunity is for full-time, permanent employment; and
3) I intend to employ the applicant in the job offer described in Part 6. of this supplement upon the approval of the applicant's Form I-485.
Individual Employer's or Authorized Signatory's Signature 8.a. Signature of Individual Employer or Authorized Signatory (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)
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Page 5, Part 8. Contact Information, Declaration, and Signature of the Person Preparing This Supplement, if Other Than the Individual Employer or Authorized Signatory of the Business Entity Employer |
[Page 5]
Part 8. Contact Information, Declaration, and Signature of the Person Preparing This Supplement, if Other Than the Individual Employer or Authorized Signatory of the Business Entity Employer
Provide the following information about the preparer.
Preparer's Full Name 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any)
Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. 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)
[Page 6]
Preparer's Statement 7.a. I am not an attorney or accredited representative but have prepared this supplement on behalf of the individual employer or authorized signatory and with the individual employer's or authorized signatory's consent.
7.b. I am an attorney or accredited representative and my representation of the individual employer or authorized signatory in this case extends/does not extend beyond the preparation of this supplement.
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, with this supplement.
Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared this supplement at the request of the individual employer or authorized signatory. The individual employer or authorized signatory then reviewed this completed supplement and informed me that he or she understands all of the information contained in, and submitted with, his or her supplement, including the Individual Employer's or Authorized Signatory's Certification, and that all of this information is complete, true, and correct.
Preparer's Signature 8.a. Preparer's Signature (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)
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[Page 5]
Part 8. Contact Information, Declaration, and Signature of the Person Preparing Parts 5. - 8. of This Supplement, if Other Than the Individual Employer or Authorized Signatory of the Business Entity Employer
Provide the following information about the preparer.
Preparer's Full Name 1.a. Preparer's Family Name (Last Name) 1.b. Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any)
Preparer's Mailing Address 3.a. Street Number and Name 3.b. Apt./Ste./Flr. [Fillable field] 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. 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)
[Page 6]
Preparer's Statement 7.a. I am not an attorney or accredited representative but have prepared this supplement on behalf of the individual employer or authorized signatory and with the individual employer's or authorized signatory's consent.
7.b. I am an attorney or accredited representative and my representation of the individual employer or authorized signatory in this case extends/does not extend beyond the preparation of this supplement.
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, with this supplement.
Preparer's Certification By my signature, I certify, under penalty of perjury, that I prepared Parts 5. - 8. of this supplement at the request of the individual employer or authorized signatory. The individual employer or authorized signatory then reviewed this completed supplement and informed me that he or she understands all of the information contained in, and submitted with, his or her supplement, including the Individual Employer's or Authorized Signatory's Certification, and that all of this information is complete, true, and correct. I completed this supplement based only on information that the individual employer or authorized signatory provided to me or authorized me to obtain or use.
Preparer's Signature 8.a. Preparer's Signature (sign in ink) 8.b. Date of Signature (mm/dd/yyyy)
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Page 7, Part 9. Additional Information |
[Page 7]
Part 9. Additional Information
If you need extra space to provide any additional information within this supplement, 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 supplement or attach a separate sheet of paper. Type or print your name and A-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.
1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name
2. A-Number
3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field]
4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field]
5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field]
6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field]
7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]
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[Page 7]
Part 9. Additional Information
If either the applicant, employer, or the preparer needs extra space to provide any additional information within this supplement, 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 supplement or attach a separate sheet of paper. Type or print your name and A-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.
1.a. Family Name (Last Name) 1.b. Given Name (First Name) 1.c. Middle Name
2. A-Number
3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. [Fillable field]
4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. [Fillable field]
5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. [Fillable field]
6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d. [Fillable field]
7.a. Page Number 7.b. Part Number 7.c. Item Number 7.d. [Fillable field]
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kim, Andrew I |
| File Modified | 0000-00-00 |
| File Created | 2021-01-12 |