Page 8,
Part 6. Applicant’s
Statement, Contact Information, Declaration, Certification, and
Signature
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[Page 8]
Part
6. Applicant’s Statement, Contact Information, Declaration,
Certification, and Signature
NOTE: Read the Penalties
section of the Form I-212 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.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 7. Read to me every questions 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 8., [fillable field] prepared this
application for me based only upon information I provided or
authorized.
Applicants Contact Information
[new]
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 USCIS may require that I submit original
document 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 the 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
6.b. Date of Signature
(mm/dd/yyyy)
NOTE
TO ALL APPLICATS: If you do not completely fill out this
application or fail to submit required documents listed in the
Instructions, USCIS may deny your application.
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[Page X]
Part
6. Applicant’s 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]
[Some of this content is now
incorporated with the red text below.]
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
7.,
understood, all of the responses and information contained in, and
submitted with, my application, and that all of the responses and
the information are 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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Page 8-9,
Part 7.
Interpreter’s Contact Information, Certification, and
Signature
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[Page 8]
Part
7. 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
Interpreters 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 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.
Interpreter’s Signature
7.a. Interpreter’s
Signature
7.b.
Date of Signature (mm/dd/yyyy)
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[Page X]
Part 7. 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 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)
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Page 9-10,
Part 8. Contact
Information, Declaration, and Signature of the Person Preparing
this Application, if Other Than the Applicant
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[Page 9]
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)
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
be obligated 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, her 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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[Page X]
Part 8. 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 and Signature
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 are 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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