Pages 2-3, Part 3.
Statement, Contact Information, Certification, and Signature of
the Person Executing This Waiver Form
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[Page 2]
Part 3. Statement, Contact
Information, Certification, and Signature of the Person Executing
This Waiver Form
NOTE: Select
the box for either Item A. or Item
B. in Item Number
1.
Statement
1. Statement
Regarding the Interpreter
A. I can read and
understand English, and I have read and understand every question,
statement, and instruction on this waiver form, and my answer or
selection for every item.
B. The
interpreter named in Part 4. read to
me every question, statement, and instruction on this waiver form,
and my answer or selection for every question, in [Fillable
Field], a language in which I am fluent, and I understood
everything.
NOTE: If
applicable, select the box for Item Number 2.
2. Statement Regarding
the Preparer
At my request, the preparer
named in Part 5., [Fillable Field],
prepared this waiver form for me based only upon information I
provided or authorized.
[new]
Person Executing This
Waiver Form’s Contact Information
3. Daytime
Telephone Number
4. Mobile
Telephone Number (if any)
5. Email
Address (if any)
Certification
Although not required in order to
submit this waiver form, if you have submitted any documents, you
must certify the following: 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 waiver form, 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 certify, under penalty of perjury,
that I provided or authorized all of the information on my waiver
form, that I understand all of the information contained with, and
submitted with my waiver form, and that all of the information is
complete, true, and correct. I further certify that I am
knowingly, intelligently, voluntarily waiving, and understand that
I will no longer be eligible for any and all of the diplomatic
rights, privileges, exemptions, and immunities that would
otherwise accrue to me under any law or executive order because of
my occupational status.
[Page 3]
Signature
6. Signature
Date of Signature (mm/dd/yyyy)
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[Page 2]
Part 3.
Contact Information, Certification, and Signature of
the Person Executing This Waiver Form
[deleted]
Provide your
daytime telephone number, mobile telephone number (if any), and
email address (if any).
Person
Executing This Waiver Form’s
Contact Information
1.
Person Executing This Waiver
Form’s Daytime
Telephone Number
2.
Person Executing This Waiver
Form’s Mobile
Telephone Number (if any)
3.
Person Executing This Waiver
Form’s Email
Address (if any)
Certification and
Signature
[deleted]
[Incorporated into the “I
certify…” paragraph]
I
certify, under
penalty of perjury, that I provided or authorized all of the
responses and information
contained in
and submitted
with my waiver form, I
read and understand or, if interpreted to me in a language in
which I am fluent by the interpreter listed in Part
4.,
understood, all of the responses and
information contained
in, and submitted
with,
my waiver
form, and that
all of the responses
and the information
is complete, true, and correct. Furthermore,
I authorize the release of any information from any and all of my
records that USCIS may need to determine my eligibility for an
immigration request and to
other entities and persons where necessary for the administration
and enforcement of U.S. immigration law.
[Page 3]
[deleted]
4. Person
Executing This Waiver Form’s
Signature
Date of Signature (mm/dd/yyyy)
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Page 3, Part 4.
Interpreter's Contact Information, Certification, and Signature
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[Page 3]
Part 4. Interpreter's
Contact Information, Certification, and Signature
Provide
the following information concerning the interpreter.
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
3.
Street Number and Name
Apt.
Ste. Flr. Number
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 3., Item B. in Item Number 1., and I have read
to the person executing this waiver form every question,
statement, and instruction on this waiver form, and his or her
answer to every item in the identified language. The person
executing this waiver form informed me that he or she understands
every instruction, statement, question, and response to every item
on this waiver form, including the Certification, and has
verified the accuracy of every response.
Interpreter's Signature
6. Interpreter's Signature
Date of Signature (mm/dd/yyyy)
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Page 3]
Part 4. 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
[deleted]
Interpreter’s
Contact Information
3.
Interpreter’s Daytime Telephone Number
4.
Interpreter’s Mobile Telephone Number (if any)
5.
Interpreter’s Email Address (if any)
Interpreter’s
Certification and
Signature
I
certify, under penalty of perjury, that
I
am fluent in
English and [Fillable language field],
and I have interpreted every question on this waiver form and
Instructions and interpreted the person executing this waiver
form’s answers to the questions in that language, and the
person executing this waiver form informed me that they understood
every instruction, question, and answer on the waiver form.
[deleted]
6.
Interpreter’s
Signature
Date of Signature (mm/dd/yyyy)
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Page 4, Part 5. Contact
Information, Declaration, and Signature of the Person Preparing
this Waver Form, if Other Than the Person Executing this Waiver
Form
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[Page 4]
Part 5. Contact
Information, Declaration, and Signature of the Person Preparing
this Waver Form, if Other Than the Person Executing this Waiver
Form
Provide the following
information about the preparer.
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. Number
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. Interpreter's
Email Address (if any)
Preparer's Statement
7. A. I am not an attorney or
accredited representative but have prepared this waiver form on
behalf of the person executing this waiver form and with that
person's consent.
B. I am an attorney or
accredited representative and my representation of the person
executing this waiver form extends/does not extend beyond the
preparation of this waiver form.
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, or Form G-28I, Notice of Entry of Appearance as
Attorney In Matters Outside the Geographical Confines of the
United States, with this waiver form.
[Page 5]
Preparer's Certification
By my signature, I certify, under
penalty of perjury, that I prepared this waiver form at the
request of the person executing this waiver form. The person
executing this waiver form then reviewed the completed waiver form
and informed me that he or she understands all of the information
contained within, and submitted with, his or her waiver form,
including the Certification, and that all of this
information is complete, true, and correct. I completed this
waiver form on behalf of the person executing this waiver form,
based only on the information that the person executing this
waiver form provided to me or authorized me to obtain or use.
Although not required in order to submit this waiver form, if the
requestor supplied additional information concerning a question on
the request, I recorded it on the request.
Preparer’s
Signature
8.
Preparer's
Signature
Date
of Signature (mm/dd/yyyy)
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[Page 4]
Part 5. Contact
Information, Declaration, and Signature of the Person Preparing
this Waver Form, if Other Than the Person Executing this Waiver
Form
[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
[deleted]
Preparer’s
Contact Information
3.
Preparer’s
Daytime Telephone Number
4.
Preparer’s
Mobile Telephone Number (if any)
5.
Preparer’s
Email Address (if any)
[deleted]
Preparer's
Certification and Signature
I
certify, under
penalty of perjury, that I prepared this waiver form for
the person executing this waiver form
at their request and with express consent and that all of the
responses and information contained in and submitted with the
waiver form is complete, true, and correct and reflects only
information provided by the person executing this waiver form.
The person executing this waiver form reviewed the responses and
information and
informed me that they understand the responses and information in
or submitted with the waiver form.
[deleted]
6.
Preparer's
Signature
Date
of Signature (mm/dd/yyyy)
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