Form I-817 Application for Family Unity Benefits

Application for Family Unity Benefits

USCIS
Form I-817

Department of Homeland Security
U.S. Citizenship and Immigration Services
Fee Stamp

For USCIS Use Only

Action Block

DRAFT
NOT FOR
PRODUCTION
07/08/2022

Resubmitted
Received
Relocated
Sent
Remarks

Initial Application

Valid

Approved

To be completed
by an attorney or
BIA-accredited
representative (if any).

From
To

Denied

/

/

Request for Extension

/

/

Select this box if
Form G-28 is
attached.

/

/

Approved

Valid

Returned

OMB No. 1615-0005
Expires 12/31/2023

From
To

Denied

/

/

/

/

/

/

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

NOTE: You must reside and file Form I-817 while in the United States.

Part 1. Information About You (Person
Requesting Family Unity Benefits)

Other Information

5.

Date of Birth (mm/dd/yyyy)

6.

U.S. Social Security Number (if any)
►

7.

USCIS Online Account Number (if any)
►

8.

Sex

9.

Country of Birth

Other Names Used

10.

Country of Citizenship or Nationality

Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 10.
Additional Information.

U.S. Mailing Address

1.

Alien Registration Number (A-Number) (if any)
► A-

Your Full Name
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Male

Female

2.c. Middle Name

11.a. In Care Of Name (if any)

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

11.b. Street Number
and Name

3.c.

11.c.

Middle Name

4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)
4.c.

Apt.

Ste.

Flr.

11.d City or Town
11.e. State

11.f. ZIP Code

Middle Name

Form I-817 Edition 12/08/21

Page 1 of 12

Part 1. Information About You (Person
Requesting Family Unity Benefits) (continued)

1.c.

On December 1, 1988, I was the spouse of an alien
who was legalized as a Special Agricultural Worker
under INA section 210.

U.S. Physical Address

1.d.

On December 1, 1988, I was the unmarried child
under 21 years of age of an alien who was a legalized
alien as a Special Agricultural Worker under INA
section 210.

DRAFT
NOT FOR
PRODUCTION
07/08/2022

12.a. Street Number
and Name
12.b.

Apt.

Ste.

Flr.

1.e.

On May 5, 1988, I was the spouse of a legalized
alien who adjusted status under section 202 of the
Immigration Reform and Control Act of 1986
(Cuban/Haitian Adjustment).

1.f.

On May 5, 1988, I was the unmarried child under
21 years of age of a person who adjusted status
under section 202 of the Immigration Reform and
Control Act of 1986 (Cuban/Haitian Adjustment).

1.g.

I am the spouse of a person who is eligible for and
has filed or adjusted status under section 1104 of
Public Law (Pub. L.) 106-553, the Legal
Immigration Family Equality (LIFE) Act. I entered
the United States on or before December 1, 1988,
and resided in the United States on that date.

1.h.

I am the unmarried child under 21 years of age of
a person who had filed an adjustment of status
application or adjusted status under section 1104
of Pub. L. 106-553, the LIFE Act. I entered the
United States on or before December 1, 1988, and
resided in the United States on that date.

12.c. City or Town
12.d. State

12.e. ZIP Code

Part 2. Biographic Information
1.

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

2.

Race (Select all applicable boxes)
White
Asian
Black or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander
3.

Height

4.

Weight

5.

Eye Color (Select only one box)

6.

Feet

Inches

Pounds

Black
Gray

Blue

Brown

Green

Hazel

Maroon

Pink

Unknown/Other

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

Black
Gray
White

Blond
Red
Unknown/Other

Part 3. Basis For Application
I am applying for Family Unity benefits because: (Select
only one box)
1.a.

1.b.

On May 5, 1988, I was the spouse of an alien who
was legalized under the Immigration and Nationality
Act (INA) section 245A.

NOTE: To be eligible for Immigration Act of 1990
(IMMACT 90) Family Unity Program benefits, your
qualifying spouse or parent must have maintained his or her
status as a legalized alien or as a U.S. citizen, if he or she
naturalized. If deceased, he or she must have maintained
status until his or her death. For LIFE Act Family Unity, your
spouse or parent must be eligible for adjustment or have
adjusted status under section 1104 of the LIFE Act. If you
previously qualified for LIFE Act Family Unity, you may be
eligible to apply for IMMACT 90 Family Unity Program
Benefits.
I am requesting: (Select only one box)
2.a.

Initial Family Unity benefits under section 301 of
IMMACT 90.

2.b.

An extension of Family Unity benefits under section
301 of IMMACT 90.

2.c.

Initial Family Unity benefits under section 1504 of
the LIFE Act Amendments.

2.d.

An extension of Family Unity benefits under section
1504 of the LIFE Act Amendments.

On May 5, 1988, I was the unmarried child under 21
years of age of an alien who was legalized under INA
section 245A.

Form I-817 Edition 12/08/21

Page 2 of 12

Part 4. Information About Your Relationship

U.S. Physical Address for Your Spouse or Parent

If you need extra space to complete Part 4., use the space
provided in Part 10. Additional Information.

10.a. Street Number
and Name
10.b.

Apt.

Ste.

Flr.

DRAFT
NOT FOR
PRODUCTION
07/08/2022

Information About Your Spouse or Parent

Provide the following information about the legalized alien
through whom you are claiming your eligibility.
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

10.c. City or Town
10.d. State

10.e. ZIP Code

11.

Daytime Telephone Number (if any)

12.

Email Address (if any)

1.c. Middle Name

Other Names Used

Provide all other names the legalized alien has ever used,
including aliases, maiden name, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Complete Only if You Are Applying Based on a
Marital Relationship or You Were Previously
Married

13. Marital Status
Married

Divorced

Widowed

Separated

Provide the following information about you and your spouse.
14.a. Number of times you have been married (including current
marriage)

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

14.b. Number of times your spouse has been married (including
spouse's current marriage)
If currently married, provide the following information about
your marriage.

3.c. Middle Name
4.

Date of Birth (mm/dd/yyyy)

5.

A-Number (if any) ► A-

Place of Marriage

6.

USCIS Online Account Number (if any)

15.b. City or Town

15.a. Date of Marriage (mm/dd/yyyy)

►
7.

U.S. Social Security Number (if any)
►

8.

Sex

9.

Class of Admission (visitor, student, EWI, etc.)

15.c. State
15.d. Province

Male

Female

15.e. Country

15.f. Type of Ceremony:
15.g. We are:

Religious

Living together

Civil

None

Not living together

15.h. If you selected "Not living together," (select only one box):
My spouse has died
We are separated

Form I-817 Edition 12/08/21

We are divorced

Page 3 of 12

Part 4. Information About Your Relationship
(continued)
Information About Your Prior Marriage

Information About Your Spouse's Prior Spouse
Provide the following information about your current spouse's
prior marriages (if any).
18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)

DRAFT
NOT FOR
PRODUCTION
07/08/2022

Provide the following information about your prior marriages
(if any).
16.a. Family Name
(Last Name)
16.b. Given Name
(First Name)

18.c. Middle Name

19.a. Date of Marriage (if any) (mm/dd/yyyy)

16.c. Middle Name

Place of Marriage

17.a. Date of Marriage (if any) (mm/dd/yyyy)

19.b. City or Town

Place of Prior Marriage

19.c. State

17.b. City or Town

19.d. Province

17.c. State
17.d. Province
17.e. Country

19.e. Country

19.f. Date of Termination (mm/dd/yyyy)
Place of Termination

17.f. Date of Termination (mm/dd/yyyy)
Place of Termination

19.g. City or Town

19.h. State

17.g. City or Town

19.i. Province
19.j. Country

17.h. State
17.i. Province

19.k. Reason for Termination
Death
Divorce

17.j. Country

Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 10. Additional Information.)

17.k. Reason for Termination
Divorce

Death

Annulment

Other (Provide an explanation if there are any other
reasons for termination. If you need extra space to
provide an explanation, use the space provided in
Part 10. Additional Information.)

NOTE: If you were previously married, you must complete
Part 4., Item Numbers 13. - 19.k. of this application; complete
all requested information about your prior marriages; and select
the box in Item Number 20. indicating that it is complete.
20.

Form I-817 Edition 12/08/21

Annulment

I have completed Part 4., Item Numbers 13. - 19.k.,
information about my prior marriages (if any).

Page 4 of 12

If divorced or widowed, provide the following information.

Part 4. Information About Your Relationship
(continued)

24.a. Date of Marriage (mm/dd/yyyy)
Place Marriage Ended

Complete Only if You Are Applying Based on a
Child/Parent Relationship

DRAFT
NOT FOR
PRODUCTION
07/08/2022
24.b. City or Town

Indicate how your parent is related to you (Select only one box)
21.a.

Biological mother

24.c. State

21.b.

Biological father who was married to my mother
when I was born

24.d. Province

21.c.

Biological father who was not married to my mother
when I was born

21.d.

Stepparent - based on marriage to my parent which
occurred before my 18th birthday

21.e.

Adoptive parent (select only one box):
A.

B.

24.e. Country

Part 5. Other Information

1.

The adoption occurred before my 16th birthday.
Yes
No
My adoptive parent had legal custody of me
on May 5, 1988 or December 1, 1988, (as
appropriate), and I resided with him or her for
two years prior to that date.
Yes

No

Have you EVER applied before for the Family Unity
Program?
Yes
No
If you answered "Yes," provide the following information.

Name Under Which You Applied
2.a. Family Name
(Last Name)
2.b. Given Name
(First Name)

Provide the following information about your marital status.

2.c. Middle Name

22.a. Marital Status
Single, Never Married
Married
Widowed
Separated

Place Where Application Was Filed

Divorced

Provide the following information.

2.e. State

23.a. Date of Marriage (mm/dd/yyyy)

2.f.

Place of Marriage

Date Filed (mm/dd/yyyy)

2.g. U.S. Citizenship and Immigration Services (USCIS) (or
former Immigration and Naturalization Service (INS))
action taken on case
Approved
Denied

23.b. City or Town

3.a. At the time of your last entry into the United States, you
(Select only one box):
Were inspected and admitted
Were inspected and paroled
Entered without inspection

23.c. State
23.d. Province
23.e. Country

23.f. Type of ceremony:
23.g. We are:

2.d. City or Town

Religious

Living together

Civil

None

Not living together

3.b. Date of Last Arrival (mm/dd/yyyy)
3.c. Form I-94 Arrival-Departure Record Number
►

23.h. If you selected "Not living together," (Select only one box):
My spouse has died
We are divorced
We are separated
Form I-817 Edition 12/08/21

Page 5 of 12

Part 5. Other Information (continued)

6.d. A-Number (if any) ► A-

3.d. Passport Number

6.e. Relationship to Applicant

3.e. Travel Document Number
3.f.

DRAFT
NOT FOR
PRODUCTION
07/08/2022

Country of Issuance for Passport or Travel Document

3.g. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
3.h. Current or Most Recent Immigration Status

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

7.c. Middle Name

7.d. A-Number (if any) ► A-

7.e. Relationship to Applicant

3.i.

Date Status Expires (mm/dd/yyyy)

3.j.

Date Continuous U.S. Residence Began (mm/dd/yyyy)

Provide the U.S. address where you lived on May 5, 1988 (INA
section 245A or Cuban Haitian Adjustment Act) or December
1, 1988 (INA section 210 or LIFE Act).

Apt.

8.c. Middle Name

8.d. A-Number (if any) ► A-

4.a. Street Number
and Name
4.b.

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

Ste.

Flr.

4.c. City or Town

8.e. Relationship to Applicant

4.e. ZIP Code

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

If you are submitting separate applications for Family Unity
benefits at this time for other relatives, provide the following
information about those other relatives.

9.c. Middle Name

NOTE: If you need extra space to complete an answer in Item
Numbers 5.a. - 24.f., use the space provided in Part 10.
Additional Information..

9.e. Relationship to Applicant

4.d. State

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name
5.d. A-Number (if any) ► A5.e. Relationship to Applicant

9.d. A-Number (if any) ► A-

10.a. Family Name
(Last Name)
10.b. Given Name
(First Name)
10.c. Middle Name
10.d. A-Number (if any) ► A10.e. Relationship to Applicant

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

Form I-817 Edition 12/08/21

Page 6 of 12

Part 5. Other Information (continued)

Previous Residence 1

List all absences from the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Form I-817,
whichever date is later.

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

Apt.

Ste.

Flr.

DRAFT
NOT FOR
PRODUCTION
07/08/2022
19.c. City or Town

11.a. Departure Date (mm/dd/yyyy)

19.d. State

11.b. Return Date (mm/dd/yyyy)

19.e. ZIP Code

19.f. Dates of Residence (mm/dd/yyyy)
From
To

12.a. Departure Date (mm/dd/yyyy)
12.b. Return Date (mm/dd/yyyy)

Previous Residence 2

13.a. Departure Date (mm/dd/yyyy)

20.a. Street Number
and Name

13.b. Return Date (mm/dd/yyyy)

20.b.

Apt.

Ste.

Flr.

20.c. City or Town

14.a. Departure Date (mm/dd/yyyy)

20.d. State

14.b. Return Date (mm/dd/yyyy)

20.e. ZIP Code

20.f. Dates of Residence (mm/dd/yyyy)
From
To

15.a. Departure Date (mm/dd/yyyy)
15.b. Return Date (mm/dd/yyyy)

Previous Residence 3

16.a. Departure Date (mm/dd/yyyy)

21.a. Street Number
and Name

16.b. Return Date (mm/dd/yyyy)

21.b.

Apt.

Ste.

Flr.

21.c. City or Town

17.a. Departure Date (mm/dd/yyyy)

21.d. State

17.b. Return Date (mm/dd/yyyy)

21.e. ZIP Code

21.f. Dates of Residence (mm/dd/yyyy)
List all residences in the United States since May 5, 1988 or
December 1, 1988, as appropriate to the section of law that
applies to you, or since the approval of your last Family Unity
application (Form I-817), whichever date is later.

Previous Residence 4

Current Residence

22.a. Street Number
and Name

18.a. Street Number
and Name

22.b.

18.b.

Apt.

Ste.

Flr.

Apt.

22.d. State

From

Form I-817 Edition 12/08/21

Ste.

Flr.

22.e. ZIP Code

22.f. Dates of Residence (mm/dd/yyyy)

18.e. ZIP Code

18.f. Dates of Residence (mm/dd/yyyy)
From
To

To

22.c. City or Town

18.c. City or Town
18.d. State

From

To

Present

Page 7 of 12

Part 5. Other Information (continued)

Have you EVER:

Previous Residence 5

26.a. Served in, been a member of, assisted in, or participated
in any military unit, paramilitary unit, police unit, selfdefense unit, vigilante unit, rebel group, guerilla group,
militia, or insurgent organization?
Yes
No

23.a. Street Number
and Name
23.b.

Apt.

DRAFT
NOT FOR
PRODUCTION
07/08/2022
Ste.

26.b. Served in any prison, jail, prison camp, detention facility,
labor camp, or any other situation that involved detaining
persons?
Yes
No

Flr.

23.c. City or Town
23.d. State

23.e. ZIP Code

27.

Have you EVER been a member of, assisted in, or
participated in any group, unit or organization of any kind
in which you or other persons used any type of weapon
against any person or threatened to do so?
Yes
No

28.

Have you EVER assisted or participated in selling or
providing weapons to any person who to your knowledge
used them against another person, or in transporting
weapons to any person who to your knowledge used them
against another person?
Yes
No

29.

Have you EVER received any type of military,
paramilitary, or weapons training?
Yes

23.f. Dates of Residence (mm/dd/yyyy)
From
To

Previous Residence 6
24.a. Street Number
and Name
24.b.

Apt.

Ste.

Flr.

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

24.e. ZIP Code

24.f. Dates of Residence (mm/dd/yyyy)
From
To

Have you EVER in the United States or Abroad:

NOTE: If you need extra space to complete an answer in Item
Numbers 5.a. - 24.f., use the space provided in Part 10.
Additional Information.
Answer Item Numbers 25.a. - 38. If you answer “Yes” to
ANY of the questions, use the space provided in Part 10.
Additional Information to provide an explanation.

30.a. Engaged in, conspired to engage in, or intended to engage
in a terrorist activity with intent to cause death or serious
bodily harm?
Yes
No

30.b. Been a representative of a terrorist organization or a
member of an organization which you knew or should have
known is a terrorist organization?
Yes
No
31.

Have you EVER ordered, incited, called for, committed,
assisted, helped with, or otherwise participated in any of the
following:
25.a. Acts involving torture or genocide?

Yes

No

25.b. Killing any person?

Yes

No

25.c. Intentionally and severely injuring any person?
Yes

Yes
25.e. Limiting or denying any person's ability to exercise
religious beliefs?
Yes

Have you EVER engaged in any activity to violate any
law of the United States related to espionage or sabotage
or to violate or evade any law prohibiting the export from
the United States of goods, technology, or sensitive
information?
Yes
No

Have you EVER:
32.a. Been convicted by a final judgment of a particularly
serious crime?
Yes
No

No

25.d. Engaging in any kind of sexual contact or relations with
any person who was being forced or threatened?

Form I-817 Edition 12/08/21

No

No

No

32.b. Participated in any other criminal activity which
endangers public safety or national security of the
United States?
Yes
33.

No

Have you EVER been convicted of any offenses for
which the aggregate sentences were five or more years
of confinement?
Yes
No

Page 8 of 12

Part 5. Other Information (continued)
34.

35.

36.

37.

38.

Applicant's Contact Information

Have you EVER been ordered deported, excluded, or
removed from the United States as you were inadmissible
at the time of entry or of adjustment of status, or violated
status?
Yes
No

Have you EVER engaged in genocide, or ordered, incited,
assisted or otherwise participated in the persecution of
any person because of race, religion, national origin,
membership in a particular social group, or political
opinion?
Yes
No
Have you EVER committed a serious nonpolitical crime
outside the United States before you arrived in the United
States?
Yes
No
Have you EVER been convicted of a felony or three or
more misdemeanors in the United States?

No

Part 6. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-817
Instructions before completing this part.

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

1.b.

I can read and understand English, and I have read and
understand every question and instruction on this
application and my answer to every question.
The interpreter named in Part 7. read to me every
question and instruction on this application and my
answer to every question in

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Applicant's Declaration and Certification

Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
I understand that USCIS may require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, if I am required to provide
biometrics, I will be required to sign an oath reaffirming that:
1)

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

2)

All of this information was complete, true, and correct at
the time of filing.

I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.

Applicant's Signature
6.a. Applicant's Signature

,
a language in which I am fluent, and I understood
everything.
2.

Applicant's Daytime Telephone Number

DRAFT
NOT FOR
PRODUCTION
07/08/2022

Have you EVER been convicted of a felony crime of
violence that has an element of or attempted use of
physical force against another individual in the course of
committing the offense?
Yes
No

Yes

1.a.

3.

6.b. Date of Signature (mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application.

At my request, the preparer named in Part 8.,
,
prepared this application for me based only upon
information I provided or authorized.

Form I-817 Edition 12/08/21

Page 9 of 12

Part 7. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.

I certify, under penalty of perjury, that:
I am fluent in English and
,
which is the same language specified in Part 6., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.

DRAFT
NOT FOR
PRODUCTION
07/08/2022

Interpreter's Full Name

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

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

2.

Interpreter's Certification

Interpreter's Business or Organization Name (if any)

Interpreter's Signature

7.a. Interpreter's Signature

Interpreter's Mailing Address

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

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

Apt.

Ste.

Flr.

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

Province

3.e. ZIP Code

3.g. Postal Code
3.h. Country

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing This
Application, 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)

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

2.

Preparer's Business or Organization Name (if any)

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

6.

Interpreter's Email Address (if any)
3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-817 Edition 12/08/21

Page 10 of 12

Part 8. Contact Information, Declaration, and
Signature of the Person Preparing This
Application, if Other Than the Applicant
(continued)

Part 9. Signature for Placement On Employment
Authorization Document
Provide your signature below. This signature will be scanned
and duplicated for placement on your Employment Authorization
Document. When signing, make sure that no part of your
signature goes outside the lines of the box.

DRAFT
NOT FOR
PRODUCTION
07/08/2022

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)

Signature

Preparer's Statement
7.a.

I am not an attorney or accredited representative
but have prepared this application on behalf of the
applicant and with the applicant's consent.

7.b.

I am an attorney or accredited representative and
my representation of the applicant in this case
extends
does not extend beyond the
preparation of this application.
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 application.

Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.

Preparer's Signature
8.a. Preparer's Signature

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

Form I-817 Edition 12/08/21

Page 11 of 12

5.a. Page Number

Part 10. Additional Information
If you need extra space to provide any additional information
within this application, 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 application or attach a separate
sheet of paper. Type or print your name and A-Number (if any)
at the top of each sheet; indicate the Page Number, Part
Number, and Item Number to which your answer refers; and
sign and date each sheet.

5.b. Part Number

5.c. Item Number

5.d.

DRAFT
NOT FOR
PRODUCTION
07/08/2022

Your Full Name

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

1.c. Middle Name
2.

A-Number (if any) ► A-

3.a. Page Number

3.d.

3.b. Part Number

6.a. Page Number

3.c. Item Number

4.b. Part Number

4.c. Item Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

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

6.b. Part Number

7.d.

4.d.

Form I-817 Edition 12/08/21

Page 12 of 12