Pages 1-5, Part 2.
Information About You
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[Page 1]
Part 2. Information About You
Your Full Name
1.a. Family Name (Last Name)
1.b. Given Name (First Name)
1.c.
Middle Name
[Page 2]
Other Names Used (if
any)
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 8. Additional Information.
2.a. Family
Name (Last Name)
2.b.
Given Name (First
Name)
2.c.
Middle Name
3.a. Family Name (Last
Name)
3.b. Given Name (First Name)
3.c.
Middle Name
Other Information
4. Alien Registration Number
(A-Number) (if any)
5. USCIS Online
Account Number (if any)
6. Date of Birth
(mm/dd/yyyy)
7. Male/Female
Place of Birth
8.a. City or Town
8.b.
State or Province
8.c. Country
9. Country of
Citizenship or Nationality
Mailing Address
10.a. In Care Of Name (if
any)
10.b. Street Number and Name
10.c. Apt./Ste./Flr.
10.d. City or Town
10.e. State
10.f. ZIP Code
10.g. Province
10.h. Postal Code
10.i. Country
Safe Mailing Address
If you are a T or U visa applicant,
and do not want U.S. Citizenship and Immigration Services (USCIS)
to send notices about this application to your home, you may
provide a safe mailing address.
11.a. In Care Of Name (if
any)
11.b. Organization Name (if
applicable)
11.c. Street Number and Name
11.d. Apt./Ste./Flr.
11.e. City or Town
11.f. State
11.g. ZIP Code
11.h. Province
11.i. Postal Code
11.j. Country
[Page
3]
Address History
Provide physical addresses for
everywhere you have lived during the last five years, whether
inside or outside the United States. Provide your current address
first. If you need extra space to complete this section, use the
space provided in Part 8. Additional Information.
Physical Address 1 (current address)
12.a. Street Number and Name
12.b. Apt./Ste./Flr.
12.c. City or Town
12.d. State
12.e. ZIP Code
12.f. Province
12.g. Postal Code
12.h. Country
Dates of Residence
13.a. From (mm/dd/yyyy)
13.b. To (mm/dd/yyyy)
Physical Address 2
14.a. Street Number and Name
14.b. Apt./Ste./Flr.
14.c. City or Town
14.d. State
14.e. ZIP Code
14.f. Province
14.g. Postal Code
14.h. Country
Dates of Residence
15.a. From (mm/dd/yyyy)
15.b. To (mm/dd/yyyy)
Physical Address 3
16.a. Street Number and Name
16.b. Apt./Ste./Flr.
16.c. City or Town
16.d. State
16.e. ZIP Code
16.f. Province
16.g. Postal Code
16.h. Country
Dates of Residence
17.a. From (mm/dd/yyyy)
17.b. To (mm/dd/yyyy)
Physical Address 4
18.a. Street Number and Name
18.b. Apt./Ste./Flr.
18.c. City or Town
18.d. State
18.e. ZIP Code
18.f. Province
18.g. Postal Code
18.h. Country
Dates of Residence
19.a. From (mm/dd/yyyy)
19.b. To (mm/dd/yyyy)
[Page 4]
Travel Information
NOTE: If you are applying for
T or U nonimmigrant status and are in the United States, you may
skip Item Numbers 20. - 25.
Location at Which you Plan to Enter
the United States (desired Port of Entry)
20.a. City
20.b. State
21. Name of Port of Entry
22. How do you plan to
travel to the United States?
(For example, by plane, ship, car)
23. When do you plan to
enter the United States? (mm/dd/yyyy)
24. Approximate Length of
Stay in the United States
25. What is the purpose of
your stay in the United States?
Explain fully below
Immigration and Criminal
History
26. Do you believe that you
may be inadmissible to the United States?
Yes
No
If you answered "Yes" to
Item Number 26., explain the reasons why you believe,
according to the best of your knowledge, that you may be
inadmissible in Part 8. Additional Information. If you were
told that you are inadmissible, provide the reason you were given.
27. Have you previously
filed an application for advance permission to enter the United
States as a nonimmigrant?
Yes
No
If you answered "Yes" to
Item Number 27., provide the details in Item Numbers 28.
- 29.e. If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
28. Date Application Filed
(mm/dd/yyyy)
Location where you filed your
application (for example, USCIS Office or Port-of-Entry).
29.a. USCIS Officer or
Port-of-Entry
29.b. City or Town
29.c. State of Province
29.d. Country
29.e. Receipt Number (if
available)
30. Have you EVER been
in the United States for a period of six months or more?
Yes
No
If you answered "Yes" to
Item Number 30., provide the dates you were in the United
States (from and to) and your immigration status at the time of
entry into the United States in the space provided in Part 8.
Additional Information.
31. Have you EVER filed
an application or petition for immigration benefits with the U.S.
Government, or has one ever been filed on your behalf?
Yes
No
If you answered "Yes" to
Item Number 31., provide the information requested in Item
Numbers 32.a. - 32.c.
If you (or somebody else on your
behalf) have filed multiple applications or petitions for
immigration benefits with the U.S. Government, use the space
provided in Part 8. Additional Information to provide the
answers to Item Numbers 32.a. - 32.c. for each of your
additional applications or petitions.
32.a. Type of Application or
Petition Filed
32.b. Location Where You (or
the Other Person) Filed the Application or Petition (for example,
USCIS office or Port-of-Entry);
32.c. Outcome of the
Application or Petition (for example, approved, denied, or is
pending).
[Page 5]
33. Have you EVER been
denied or refused an immigration benefit by the U.S. Government,
or had a benefit revoked or terminated (including but not limited
to visas)?
Yes
No
If you answered "Yes" to
Item Number 33., provide an explanation the information in
the space provided in Part 8. Additional Information.
34. Have you EVER, in
or outside the United States, been arrested, cited, charged,
indicted, fined, convicted, or imprisoned for breaking or
violating any law or ordinance, excluding minor traffic
violations?
Yes
No
If you answered "Yes" to
Item Number 34., describe the incidents in detail and
include all offenses where impaired driving may have been an issue
in the space provided in Part 8. Additional Information.
[This content formerly Item
Numbers 20.a. – 25.]
[This content formerly Item Numbers 1. - 8.b. in Part
4. Other Information About You]
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Part
2. Information About You
[deleted]
1.
Your
Full Legal
Name
(Do not provide a nickname)
Family
Name (Last Name)
Given Name
(First Name)
Middle Name
(if applicable)
2.
Other Names Used
(if any)
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 6.
Additional Information.
Family Name (Last Name) [x
2]
Given Name (First Name) [x
2]
Middle Name (if applicable)
[x 2]
Other Information
3.
Alien Registration Number (A-Number) (if
any)
4.
USCIS Online Account Number (if
any)
5.
Date of Birth
(mm/dd/yyyy)
[renumbered
and moved down]
6.
Place
of Birth
City
or Town
State
or Province
Country
7.
Country
of Citizenship or Nationality
8.
Gender
Male
Female
Another Gender
Identity
9.
Mailing Address (Safe
address, if applicable)
Please provide
an address where you can safely receive correspondence from USCIS.
In Care Of Name (if any)
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
[deleted]
Address History
Provide physical addresses for
everywhere you have lived during the last five years, whether
inside or outside the United States. Provide your current address
first. If you need extra space to complete this section, use the
space provided in Part 6.
Additional Information.
10.
Physical Address 1 (current address)
Street
Number and Name
Apt./Ste./Flr.
Number
City or
Town
State
ZIP
Code
Province
Postal
Code
Country
Dates of Residence
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
11.
Physical Address 2
Street
Number and Name
Apt./Ste./Flr.
Number
City or
Town
State
ZIP
Code
Province
Postal
Code
Country
Dates of Residence
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
[deleted]
[renumbered
and moved down to Item Numbers 37.
– 43.]
Information
About Your Marital History
12.
What is your current marital status?
Single, Never
Married
Married
Divorced
Widowed
Legally
Separated
Marriage
Annulled
Other
13.
How many times have you been married (including annulled
marriages and marriages to the same person)?
[Page 7]
Information
About Your Current Marriage (including
if you are legally separated)
If you are
currently married, provide the following information about your
current spouse.
14.
Current Spouse's Legal Name
Family Name
(Last Name)
Given Name
(Last Name)
Middle Name
(if applicable)
15.
Spouse’s Alien Registration Number (A-Number) (if any)
16.
Date of Birth (mm/dd/yyyy)
17.
Date of Marriage (mm/dd/yyyy)
18. Place
of Birth
City or Town
State of
Province
Country
19. Place
of Marriage
City or Town
State or
Province
Country
Information
About Prior Marriages (if
any)
If you have
been married before, anywhere in the world, provide the
information requested in Item
Numbers 20. - 25. about your
prior marriage. If you have had more than one previous marriage,
use the space provided in Part 6.
Additional Information to provide
the answers to Item Numbers 20. -
25. for each additional marriage.
20. Prior
Spouse's Legal Name (provide family name before marriage)
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
(if applicable)
21.
Date of Birth (mm/dd/yyyy)
22.
Date of Marriage (mm/dd/yyyy)
23. Place
of Marriage
City or Town
State or
Province
Country
24.
Date Marriage Legally Ended (mm/dd/yyyy)
25. Place
Where Marriage Legally Ended
City or Town
State or
Province
Country
Immigration and Criminal
History
26. Explain
the grounds of inadmissibility that may apply in your case in Part
6. Additional Information.
[deleted]
27.
Have you previously filed an application for advance
permission to enter the United States as a nonimmigrant?
Yes
No
If you answered "Yes" to
Item Number 27., provide the details in Item Numbers 28.
- 29. If you need extra space to complete this section, use
the space provided in Part 6.
Additional Information.
28. Date Application Filed
(mm/dd/yyyy)
29.
Location where you filed your application (for example, USCIS
Office or Port of Entry).
USCIS
Office or Port of Entry
City or
Town
State
of Province
Country
Receipt
Number (if available)
30. Have you EVER been
in the United States for a period of six months or more?
Yes
No
If you answered "Yes" to
Item Number 30., provide the dates you were in the United
States (from and to) and your immigration status at the time of
entry into the United States in the space provided in Part 6.
Additional Information.
31. Have you EVER filed
an application or petition for immigration benefits with the U.S.
Government, or has one ever been filed on your behalf?
Yes
No
If you answered "Yes" to
Item Number 31., provide the information requested in Item
Numbers 32. - 34.
If you have
(or somebody else on your behalf has)
filed multiple applications or
petitions for immigration benefits with the U.S. Government, use
the space provided in Part 6.
Additional Information to provide the answers to Item
Numbers 32. - 34.
for each of your additional applications or petitions.
32.
Type of application or petition
filed
33.
Location the application or petition
was filed (for example, USCIS office or Port of Entry)
34.
Outcome of the application or
petition (for example, approved,
denied, or pending).
35.
Have you EVER been denied or refused an immigration
benefit by the U.S. Government, or had a benefit revoked or
terminated (including but not limited to visas)?
Yes
No
If you answered "Yes" to
Item Number 35.,
provide an explanation the information in the space provided in
Part 6. Additional
Information.
36.
Have you EVER, in or outside the United States,
been arrested, cited, charged, indicted, fined, convicted, or
imprisoned for breaking or violating any law or ordinance,
excluding minor traffic violations?
Yes
No
If you answered "Yes" to
Item Number 36.,
describe the incidents in detail and include all offenses where
impaired driving may have been an issue in the space provided in
Part 6. Additional
Information.
Travel
Information
NOTE: If
you are applying for T or U nonimmigrant status and are in the
United States, you may skip Item
Numbers 37. - 43.
Location at
Which you Plan to Enter the United States (desired Port of Entry)
37.
City
38. State
39. Name
of Port of Entry
40.
How do you plan to travel to the United States?
(For example,
by plane, ship, car)
41.
When do you plan to enter the United States? (mm/dd/yyyy)
42.
Approximate Length of Stay in the
United States
43.
What is the purpose of your stay in the United States?
Explain fully
below
Employment History
Provide your employment history for
the last five years, whether inside or outside the United States.
Provide the most recent employment first. If you need extra space
to complete this section, use the space provided in Part 6.
Additional Information.
44.
Employer 1 (current or most recent)
Name of Employer or Company
Address of Employer or Company
Street
Number and Name
Apt
Ste. Flr. Number
City or
Town
State
ZIP
Code
Province
Postal
Code
Country
Your
Occupation
Dates of Employment
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
45.
Employer 2
Name of Employer or Company
Address of Employer or Company
Street
Number and Name
Apt
Ste. Flr. Number
City or
Town
State
ZIP
Code
Province
Postal
Code
Country
Your
Occupation
Dates of Employment
From
(mm/dd/yyyy)
To
(mm/dd/yyyy)
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Pages 5-7, Part 4.
Other Information About You
|
[Page 5]
Part 4. Other Information About
You
Employment History
Provide your employment history for
the last five years, whether inside or outside the United States.
Provide the most recent employment first. If you need extra space
to complete this section, use the space provided in Part 8.
Additional Information.
Employer 1 (current or most recent)
1. Name of Employer or
Company
Address of Employer or Company
2.a. Street Number and Name
2.b. Apt/Ste./Flr.
2.c. City or Town
2.d. State
2.e. ZIP Code
2.f. Province
2.g. Postal Code
2.h. Country
3. Your Occupation
Dates of Employment
4.a. From (mm/dd/yyyy)
4.b. To (mm/dd/yyyy)
[Page 6]
Employer 2 (current or most recent)
5. Name of Employer or
Company
Address of Employer or Company
6.a. Street Number and Name
6.b. Apt/Ste./Flr.
6.c. City or Town
6.d. State
6.e. ZIP Code
6.f. Province
6.g. Postal Code
6.h. Country
7. Your Occupation
Dates of Employment
8.a. From (mm/dd/yyyy)
8.b. To (mm/dd/yyyy)
Information About Your Parents
Information About Your Mother
Mother’s Legal Name
9.a. Family Name (Last Name)
9.b. Given Name (First Name)
9.c. Middle Name
Mother’s Name at Birth (if
different than above)
10.a. Family Name (Last
Name)
10.b. Given Name (First
Name)
10.c. Middle Name
11. Date of Birth
(mm/dd/yyyy)
12. City or Town of Birth
13. Country of Birth
14. Current City or Town of
Residence (if living)
15. Current Country of
Residence (if living)
Information About Your Father
Father’s Legal Name
16.a. Family Name (Last
Name)
16.b. Given Name (First
Name)
16.c. Middle Name
Father’s Name at Birth (if
different than above)
17.a. Family Name (Last
Name)
17.b. Given Name (First
Name)
17.c. Middle Name
18. Date of Birth
(mm/dd/yyyy)
19. City or Town of Birth
20. Country of Birth
21. Current City or Town of
Residence (if living)
22. Current Country of
Residence (if living)
Information About Your Marital
History
23. What is your current
marital status?
Single, Never Married
Married
Divorced
Widowed
Legally Separated
Marriage Annulled
Other
24. How many times have you
been married (including annulled marriages and marriages to the
same person)?
[Page 7]
Information About Your Current
Marriage (including if you are legally separated)
If you are currently married,
provide the following information about your current spouse.
Current Spouse's Legal Name
25.a. Family Name (Last
Name)
25.b. Given Name (Last Name)
25.c. Middle Name
26. A-Number (if any)
27. Current Spouse’s
Date of Birth (mm/dd/yyyy)
28. Date of Marriage to
Current Spouse (mm/dd/yyyy)
Current Spouse’s Place of
Birth
29.a. City or Town
29.b. State of Province
29.c. Country
Place of Marriage to Current Spouse
30.a. City or Town
30.b. State or Province
30.c. Country
Information About Prior
Marriages (if any)
If you have been married before,
whether in the United States or in any other country, provide the
information requested in Item Numbers 31.a. - 36.c. about
your prior marriage. If you have had more than one previous
marriage, use the space provided in Part 8. Additional
Information to provide the answers to Item Numbers 31.a. -
36.c. for each additional marriage.
Prior Spouse's Legal Name (provide
family name before marriage)
31.a. Family Name (Last
Name)
31.b. Given Name (First
Name)
31.c. Middle Name
32. Prior Spouse’s
Date of Birth (mm/dd/yyyy)
33. Date of Marriage to
Prior Spouse (mm/dd/yyyy)
Place of Marriage to Prior Spouse
34.a. City or Town
34.b. State or Province
34.c. Country
35. Date Marriage with Prior
Spouse Legally Ended (mm/dd/yyyy)
Place Where Marriage with Prior
Spouse Legally Ended
36.a. City or Town
36.b. State or Province
36.c. Country
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[deleted]
[Renumbered
and reorganized into Part 2.
Information About You.]
[deleted]
[Renumbered
and reorganized into Part 2.
Information About You.]
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Page 8, Part 5.
Applicant's Statement, Contact Information, Declaration,
Certification, and Signature
|
[Page 8]
Part 5. Applicant's Statement,
Contact Information, Declaration, Certification, and Signature
NOTE: Read the Penalties
section of the Form I-192 Instructions before completing this
section.
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.a. 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.
1.b. The interpreter named
in Part 6. read to me every question and instruction on
this application and my answer to every question in [fillable
field], a language in which I am fluent, and I understood
everything.
2. At my request, the
preparer named in Part 7., [fillable field], prepared this
application 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 Declaration and
Certification
Copies of any documents I have
submitted are exact photocopies of unaltered, original documents,
and I understand that the U.S. Department of Homeland Security
(DHS) may require that I submit original documents to DHS at a
later date. Furthermore, I authorize the release of any
information from any and all of my records that DHS 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 DHS records, to other entities and persons
where necessary for the administration and enforcement of U.S.
immigration law.
I understand that DHS 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.
[new]
Applicant’s Signature
6.a. Applicant’s
Signature
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.
|
Part
3.
Applicant’s Statement, Contact
Information, Certification,
and Signature
[deleted]
Applicant’s
Contact Information
Provide your
daytime telephone number, mobile telephone number (if any), and
email address (if any).
1.
Applicant’s
Daytime Telephone Number
2.
Applicant’s
Mobile Telephone Number (if any)
3.
Applicant’s
Email Address (if any)
Applicant’s
Certification and Signature
[deleted]
I
certify, under penalty of perjury, that I provided or authorized
all of the responses and information contained in and submitted
with my application, 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 application, 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.
[deleted]
4.
Applicant’s Signature
Date of
Signature (mm/dd/yyyy)
[deleted]
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Pages 8-9, Part 6.
Interpreter's Contact Information, Certification, and Signature
|
[Page 8]
Part 6. Interpreter's Contact
Information, Certification, and Signature
Provide the following information
about the interpreter.
Interpreter's Full Name
1.a. Interpreter’s
Family Name (Last Name)
1.b. Interpreter’s
Given Name (First Name)
2. Interpreter’s
Business or Organization Name (if any)
[Page 9]
Interpreter's Mailing Address
3.a. Street Number and Name
3.b. Apt./Ste./Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f. Province
3.g. Postal Code
3.h. 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 5.,
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.
Interpreter’s Signature
7.a. Interpreter’s
Signature
7.b. Date of Signature
(mm/dd/yyyy)
|
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
5.
Interpreter’s
Email Address
Interpreter’s
Certification
I
certify, under penalty of perjury, that I am fluent in English and
[Fillable language field], and I have interpreted every question
on the application and instructions and interpreted the
applicant’s answers to the questions in that language, and
the applicant
informed
me that they understood every instruction, question, and answer on
the application.
[deleted]
6.
Interpreter’s
Signature
Date
of Signature (mm/dd/yyyy)
|
Pages 9-10, Part 7.
Contact Information, Declaration, and Signature of the Person
Preparing this Application, if Other Than the Applicant
|
[Page 9]
Part 7. 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)
2. Preparer’s Business
or Organization Name (if any)
Preparer’s Mailing
Address
3.a. Street Number and Name
3.b. Apt./Ste./Flr.
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 10]
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 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 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)
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Part
5. Contact
Information, Declaration, and Signature of the Person Preparing
this Application, if Other Than the Applicant
[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
I
certify, under penalty of perjury, that I prepared this
application
for the applicant
at their request and with express consent and that all of the
responses and information contained in and submitted with the
application is complete, true, and correct and reflects only
information provided by the applicant. The applicant reviewed the
responses and information and informed me that they understand the
responses and information in or submitted with the application.
[deleted]
6.
Preparer’s
Signature
Date of
Signature (mm/dd/yyyy)
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