DS-7656 Affidavit of Relationship

U.S. Department of State AFFIDAVIT OF RELATIONSHIP (AOR)

OMB APPROVAL NO. XXXX-XXXX EXPIRES: XX-XX-XXXX ESTIMATED BURDEN: XX minutes *

1. What is the purpose of this form?

By completing Form DS-7656, Affidavit of Relationship (AOR), you are claiming a relationship with family members overseas to help determine if they are qualified to apply for admission to the United States under the U.S. Refugee Admissions Program (USRAP). The form itself is not an application for your family members’ admission to the United States as a refugee under the USRAP or a petition for any immigration benefit under U.S. law. Completion of this form does not guarantee that your family members will qualify to apply for refugee admission or that they ultimately will be admitted to the United States. Eligibility for access to the USRAP varies from year to year as outlined in the annual Presidential Report to Congress on Proposed Refugee Admissions. Resettlement agency representatives, who assist persons with this form, are knowledgeable about who may file an AOR in the current year. This form also assists the U.S. Department of Homeland Security's U.S. Citizenship and Immigration Services (USCIS) to verify family relationships during refugee case adjudication. The main purpose of the form is for you, the U.S.-based family member, to provide biographical information about relatives overseas who may subsequently seek access to the USRAP for verification by the U.S. government. The information on this form may also be used by the U.S. government to verify information provided by these individuals in relation to any other immigration benefit they may subsequently seek under U.S. law and other uses as described in the Privacy Act Statement on the AOR and in Part 10 of these instructions below.

2. Who may file this form?

You may file this form if you are at least 18 years old and have been admitted to the United States or granted status as either a(n):

1. refugee;

2. asylee;

3. U.S.-based Afghan Special Immigrant Visa (SIV) recipient; or

4. U.S.-based Iraqi Special Immigrant Visa (SIV) recipient.

Additionally, you must have been granted status no more than five years prior to filing this form.

3. Who can apply for refugee admission based on this form?

The following family members may be qualified to apply for refugee admission to the United States under the USRAP, if they have valid proof of registration in their country of asylum:

1. Your spouse

2. Your unmarried (single, widowed or divorced) child(ren) under the age of 21

3. Your parents

Each of these family members are referred to as a Qualifying Family Member (QFM).

If the QFM is determined to be qualified to apply for refugee admission to the United States, their spouse and any unmarried children under the age of 21 included on the form may also apply for refugee admission together with the QFM. These individuals derive their refugee status from the QFM and do not have to independently establish a persecution claim. These individuals are considered "Type B” relatives on this form.

On a case-by-case basis, a person may also be allowed to apply with the QFM for possible refugee admission, if that individual:

1. lived in the same household as the QFM in the country of nationality or, if stateless, last habitual residence; AND,

2. was part of the same economic unit as the QFM in the country of nationality or, if stateless, last habitual residence; AND,

3. demonstrates exceptional and compelling humanitarian circumstances that justify their inclusion on the QFM’s case.

These individuals cannot derive their refugee status from the QFM and therefore must independently establish that they qualify as a refugee. These individuals are considered "Type C” individuals on this form.

Please note:

• The relationship between you and the QFM must have existed on the date you were admitted to the United States as a refugee or SIV recipient, or were granted asylum in the United States, and must continue to exist.

• All family members that qualify as a QFM should be listed as a QFM in Section II, even if they could also qualify as a “Type B” relative.

• If a person who is listed on this form is a child who was conceived but not yet born on the date you were admitted to the United States as a refugee or SIV recipient, or granted asylum in the United States, the relationship will be considered to exist as of the date you were admitted to the United States as a refugee or granted asylum in the United States. The mother of any such child is not a QFM unless the mother was married to you when you were admitted to the United States as a refugee or granted asylum in the United States.

• The marriage creating a stepparent or stepchild relationship must have occurred before the child's 18th birthday for the stepparent or stepchild to be claimed on this form as a QFM or “Type B” relative (i.e., a spouse or unmarried child under 21 of the QFM) .

• Adopted Children: To be claimed on this form as QFMs in Section II or as “Type B” relatives in Section II, adopted children must have been in the legal custody of and resided with the adopting parent or parents for at least two years and:

1. been legally adopted before their 16th birthday, or

2. be the natural sibling of a child described in (a) directly above and been adopted themselves before their 18th birthday.

• In all cases, for your children/stepchildren/adopted children to be considered QFMs, they must be unmarried and under the age of 21 when this form is filed and continue to be unmarried at the time of admission to the United States.

4. Where do you file this form?

The form is prepared by you with assistance from a local resettlement agency participating in the U.S. Department of State's Refugee Reception and Placement Program and submitted to the U.S. Department of State by the resettlement agency's national headquarters office. Forms submitted directly to Resettlement Support Centers (RSCs) or by you to the U.S. government will NOT be accepted.

5. What additional information must be provided with this form?

You must attach copies of documents that provide proof of registration in the country of asylum for the family members for whom you are applying. Registration documents are provided by the United Nations High Commissioner for Refugees (UNHCR) or the country of asylum.

You must attach copies of documents that provide proof of your current legal immigration status in the United States. Forms submitted without such document(s) will NOT be accepted.

Acceptable proof of current legal immigration status:

1. Refugees, SIV Recipients, and Asylees: Legible copy of both sides of your Form I-94, a copy of U.S. Customs and Border Protection-endorsed visa, permanent resident card, a copy of your asylum grant letter, or immigration judge grant decision.

2. Lawful Permanent Residents: Legible copy of both sides of your Form I-551 (Permanent Resident Card - Green Card), any temporary proof of permanent resident status issued by USCIS, or documents that were formerly issued by the Immigration and Naturalization Service.

3. U.S. Citizens: Legible copy of your U.S. passport or naturalization certificate (Note: it is now legal to make a copy of this document for immigration purposes.)

Where possible, you must attach copies of documents that provide proof that a relationship exists between you and your QFM(s) or any derivative applicant(s). If the documents described below are not available, see the sections of these instructions entitled "What if a document is not available?" and "What if secondary evidence is not available?" Applicants who do not have and cannot reasonably obtain these documents will be required to provide a DNA sample to establish their relationship.

Acceptable proof of relationship between you and your spouse:

Legible copy of your marriage certificate and the birth certificate of your spouse. If you or your spouse were previously married to other people, submit evidence of the legal termination of the previous marriage(s), such as a divorce or death certificate. Evidence of any legal name change must also be submitted, if applicable.

Acceptable proof of relationship between you and your biological child:

1. If you’re the mother: Legible copy of the child's birth certificate showing both the child's name and your name. Evidence of any legal name change must also be submitted if the names on the birth certificate do not match the names on this form.

2. If you’re the father: Legible copy of the child's birth certificate showing both the child's name and your name. If you were married to the child's mother at the time of birth, submit your marriage certificate. If you or the child's mother were previously married to other people, submit evidence of the legal termination of the previous marriages.


If you were not married to the child's mother at the time of birth, you must either 1) submit evidence that the child was legitimated by civil authorities of the U.S.-based family member or child’s residence, or 2) submit evidence that a bona fide parent/child relationship exists or existed between you and the child. Evidence of a bona fide parent/child relationship should provide that you have emotional and financial ties to the child and that you have shown genuine interest in the child's general welfare.
Such evidence may include (but is not limited to) the following:

1. Money order receipts

2. Canceled checks showing financial support of the child

3. Income tax returns in which you claim the child as a dependent and a member of your household

4. Medical or insurance records that include the child as a dependent

5. School records for the child

6. Correspondence between you and the child

7. Notarized affidavits of reliable persons who are knowledgeable about the relationship.

Evidence of any legal name change must also be submitted, if applicable.

Acceptable proof of relationship between you and your stepchild:

Legible copy of the child's birth certificate and the marriage certificate between you and the child's natural parent. If you or the child's natural parent were ever previously married to other people, submit evidence of the legal termination of the previous marriage(s).
Evidence of any legal name changes must also be submitted, if applicable.

Acceptable proof of relationship between you and your adopted child:

Legible certified copy of the adoption decree and evidence that you resided together with the child for at least two years. If you were granted legal custody of the child prior to the adoption, submit a certified copy of the court order granting custody. Evidence of any legal name changes must also be submitted, if applicable.

Acceptable proof of relationship between you and your parent(s):

Legible copy of your birth certificate showing both your name and your parent’s name. Evidence of any legal name change must also be submitted if the names on the birth certificate do not match the names on this form.

What if a document is not available?

If the document(s) described above are not available from the civil authorities, you must submit the following, as secondary evidence, along with a statement from the appropriate civil authority certifying that the required document(s) is (are) not available.

1. Religious Institution Record: A certificate under the seal of the religious institution where the baptism, dedication, or comparable rite occurred within two months after birth, showing the date and place of the child's birth, the date of the religious ceremony, and the names of the child's parents.

2. School Record: A letter from the authorities of the school attended, showing the date of admission to the school, the child's date and place of birth, and the names of both parents, if shown on the school records.

3. Census Record: State or Federal census record showing name, place of birth, and date of birth, or the age of the person(s) listed.

What if secondary evidence is not available?

If the secondary evidence described above is not available, you can submit affidavits. If you submit affidavits, they must overcome the absence of primary and secondary evidence.

Affidavits

Submit written statements sworn to or affirmed by two persons who were living at the time and who have personal knowledge of the event you are trying to prove: for example, the date and place of birth, marriage, divorce, or death. The persons making the affidavits do not have to be U.S. citizens or be based in the United States.

Each affidavit should contain the following information regarding the person making the affidavit: their full name, address, date and place of birth and their relationship to you, if any; full information concerning the event; and complete details concerning how the person acquired the knowledge of the event.

6. What other information may be needed to establish a family relationship?

You and your biological parent(s) and/or child(ren) listed as QFM(s) in Section II of this form may be required to provide a DNA sample to establish your relationship. By signing your name on this form, you are agreeing to provide the DNA sample when requested by an official of the U.S. government or its designated representatives. Note that if you or your QFM(s) fail to submit DNA evidence upon request, your QFM(s) may be considered ineligible to apply for refugee resettlement. Further, by signing this form, you are expressing your understanding that the U.S. government or its designated representatives may suggest DNA testing for your QFM(s) and any derivative applicant(s) (unmarried child under the age of 21) if they are unable to prove the existence of their claimed family relationship. Failure to submit DNA evidence may result in the derivative applicant(s) being considered ineligible for refugee resettlement.

An officer of USCIS will make the final determination regarding whether a bona fide relationship exists between you and your relative(s) at the time of the interview for refugee status.

7. Who will cover the costs of DNA testing?

The U.S. government will pay for the cost of any DNA testing for you and your biological parent or child listed in Section II as the QFM. DNA testing between your QFM and any derivative applicant(s) (unmarried child under the age of 21), to prove the existence of their claimed family relationship, will be at no expense to the U.S. government.

8. What are the instructions for completing this form?

1. This form must be completed in English.

2. You must be at least 18 years old to file this form.

3. You are responsible for providing detailed information to the best of your knowledge. If you do not have all the information required, BUT you can obtain the information, wait to complete this form until all the information is received.

4. Section I: This section is for information about you, the U.S.-Based Family Member.

5. Section II: This section is for your QFM(s) seeking access to the USRAP and their “Type B” relative(s) (spouse or unmarried child(ren) under 21) and/or “Type C” individuals (member(s) of the same economic unit) who wish to be considered for resettlement at this time.

   1. Line 1: Provide the requested information only for your spouse, parent, or unmarried child(ren) under age 21.

   2. Line 2-16: List from oldest to youngest, the spouse and/or unmarried children under age 21 of the QFM named on line 1 who wish to be considered for resettlement at this time. Enter "B" in the box under "Type" to specify that this person is the spouse or child of the QFM. If applicable, also include individuals who were part of the same household/economic unit of the QFM named on Line 1 in the country of origin/nationality and explain the exceptional and compelling circumstances justifying their inclusion on this form in the Section IV. For these individuals, enter "C" in the box under "Type" to specify that this person is a member of the same economic unit as the QFM named on line 1.

   3. Use a separate page for each QFM you are claiming. List the QFM’s dependents and any members of household/economic unit on that page. You may use as many pages as necessary to include each QFM you are claiming.

   4. Attach current and valid proof registration in country of asylum for all individuals in Section II.

6. Section III: Include a passport style photo for each person listed in Section II. Frame the photo as a front view of the applicant’s full face, from the top of the head to the shoulders with eyes open.

7. Section IV: Use this section to elaborate on any extended or non-traditional relationships that may require further explanation (including adopted, half, and step relatives), any unusual name patterns, any aliases, or any unusual circumstances that you wish to address.

8. Section V: Read the certification and then sign your name, print your name, and fill in the date. You will be asked to provide valid identification to the resettlement agency representative who assisted you to fill out this form. The resettlement agency representative will then sign the form, print their name, date the form, and provide the affiliate name, address, and telephone number.

9. Answer all questions fully and accurately. If you do not know the answer to a question, write "Unknown." If questions asked do not apply to you, state "N/A," which means “Not Applicable.” For all persons, if the Date of Birth is not known, provide an estimate; if the City and Country of Birth is not known, provide the best guess and then explain in Section IV.

10. Use the relationship types provided below to indicate relationships between persons, as requested on this form.

11. Always give exact dates of birth and of significant events, like marriage, if they are known. Otherwise, if you can, provide the best-estimated date. All dates must comply with the following format: DD MMM YYYY (14 JAN 1965).

12. Use a complete name each time a name is requested. Do not use initials. If the person has a patronymic, substitute the patronymic for the middle name. If the middle name of the person has only one letter, or if there is any different naming structure, this should be clarified in Section IV. If anyone uses an alias, provide that information in Section IV or on a supplemental sheet.

13. If there is insufficient space in any section, continue in Section IV or use supplemental sheets.

14. No resettlement agency representative or USRAP processing partner may solicit or accept money or any other favor to prepare, file, or process this form.

9. What penalties do people face for committing fraud?

• Title 8, United States Code, Section 1325(c), states that any person who knowingly enters into a marriage for the purpose of evading any provision of the immigration laws shall be imprisoned for not more than five years, or fined not more than $250,000, or both.

• Title 18, United States Code, Section 1001, states that whoever willfully and knowingly falsifies a material fact, makes a materially false statement, or makes use of a false document knowing the same to contain any materially false statement will be fined up to $10,000 or imprisoned up to five years, or both.

• If it is determined that a genuine relationship does not exist between you and the person(s) you are claiming as your relative(s), then processing of their admission to the United States, and that of their family members, may be terminated.

• Misrepresenting your relationship to an individual(s) so that such individual(s) may gain access to the USRAP could make you inadmissible to the United States, make you ineligible for certain immigration benefits, and/or render you subject to removal.

10. What authority do we have to collecting this information and how may we use it?

The U.S. Department of State requests the information on this form, including the agreement of the U.S.-based family member to provide a DNA sample at a later date, to carry out the immigration laws contained in Title 8, United States Code, Section 1157. The U.S. Department of State requests this information to assist in determining whether a family member claimed on this form is qualified to apply for access to the U.S. Refugee Admissions Program (USRAP) for purposes of family reunification. The information you provide may also be disclosed to a) the U.S. Department of Homeland Security for purposes of determining whether your relatives are eligible for admission to the United States and for verifying information provided by the family members listed on this form in any application they may make for admission to the United States under the USRAP or for any other immigration benefit under U.S. law; b) Members of Congress or other Federal, State, and local government agencies having statutory or other lawful authority, as needed for the formulation, amendment, administration, or enforcement of immigration, nationality, and other laws of the United States; and, c) international organizations and resettlement agency partners that work with the USRAP to enable them to coordinate and manage refugee processing overseas and resettlement in the United States. You do not have to complete this form and provide the requested information; however, if you refuse to provide some or all information, your relative's access to the USRAP for refugee resettlement consideration may be denied.

11. Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to U.S. Department of State, A/GIS/IPS, 2025 E Street, NW Washington DC, 20520. OMB No. 1405-0206.

12. List of Relationship Types

Use these relationship types on Section II of the form.

Spouse Relationships
Husband	Wife	Minor Wife	Union with Male
Union with Female	Ex-Husband	Ex-Wife	Fiancé(e)

Child Relationships
Daughter (Biological)	Son (Biological)	Adopted Daughter	Adopted Son
Stepdaughter	Stepson	Foster Daughter	Foster Son

Parent Relationships
Father (Biological)	Mother (Biological)	Adopted Father	Adopted Mother
Stepfather	Stepmother	Foster Father	Foster Mother

Sibling Relationships
Brother (Biological)	Sister (Biological)	Adopted Brother	Adopted Sister
Stepbrother	Stepsister	Half Brother	Half Sister
Foster Brother	Foster Sister

Other Relationships
Aunt	Uncle	Niece	Nephew
Cousin (Female)	Cousin (Male)	Father-in-Law	Mother-in-Law
Daughter-in-Law	Son-in-Law	Husband’s Brother	Husband’s Sister
Wife’s Brother	Wife’s Sister	Grandfather	Grandmother
Granddaughter	Grandson	Great Grandfather	Great Grandmother
Great Granddaughter	Great Grandson	Relative by Marriage	Distant Relative
Friend	Guardian	Unaccompanied Minor	Unknown Relationship
Unrelated

`			U.S. Department of State AFFIDAVIT OF RELATIONSHIP (AOR)					OMB APPROVAL NO. XXXX-XXXX EXPIRES: XX-XX-XXXX ESTIMATED BURDEN: XX minutes *
Date Completed (e.g. 05 JAN 2010)	Case File ID Number (A# Number)					Name of National Resettlement Agency				Affiliate ID Number
SECTION I: Information about the U.S.-Based Family Member
(a) Name (Last, First, Middle)									(b) Date of Birth (e.g. 05 JAN 2010)
(c) Gender Male Female X		(d) Current Marital Status Single Married Divorced Separated Widow(er)
(e) Current Spouse (Last, First, Middle)							(f) City and Country of Birth
(g) Current U.S. Address Street _____________________________________________ City _______________________________ State _____ ZIP ______________
(h) Phone Number
(i) E-mail Address				(j) Date of Admission to the United States (if refugee or SIV recipient) or Date Asylum was Granted (if asylee)
(k) Current U.S. Immigration Status (Check One) U.S. Citizen - Certificate Number ________________________ Lawful Permanent Resident Asylee Refugee Other (Please explain) ________________________________					(l) If the U.S.-Based Family Member was admitted as a refugee, complete the following: Country of Processing __________________________________________ Oversees Case Number, if known _________________________________
Important Notice By completing Form DS-7656, Affidavit of Relationship (AOR), you are claiming a relationship with one or more family members overseas to help determine if they are qualified to apply for admission to the United States under the U.S. Refugee Admissions Program (USRAP). The form itself is not an application for your family members’ admission to the United States as a refugee under the USRAP or a petition for any immigration benefit under U.S. law. Completion of this form does not guarantee that your family members will qualify to apply for refugee admission or that they ultimately will be admitted to the United States. The U.S. government investigates family relationships and verifies all documents. Criminal prosecutions may be sought when family relationships are falsified to obtain immigration benefits.
Privacy Act Statement AUTHORITIES: The information is sought pursuant to carrying out the immigration laws contained in Title 8, United States Code, Section 1157. PURPOSE: The information solicited on this form, including the agreement of the U.S.-based family member to provide a DNA sample at a later date, will be used to assist in determining whether a family member claimed on this form is qualified to apply for access to the U.S. Refugee Admissions Program (USRAP) for purposes of family reunification. ROUTINE USES: The information on this form may be shared with the U.S. Department of Homeland Security for purposes of determining whether your spouse, parent(s), and child(ren) and their derivatives are eligible for admission to the United States and for verifying information provided by your spouse, parent(s), and child(ren) listed on this form in any application they may make for admission to the United States under the USRAP or for any other immigration benefit under U.S. law. The information may also be made available to Members of Congress or other Federal, State, and local government agencies having statutory or other lawful authority, as needed for the formulation, amendment, administration, or enforcement of immigration, nationality, and other laws of the United States and to international organizations and resettlement agency partners that work with the USRAP to enable them to coordinate and manage refugee processing overseas and resettlement in the United States. More information on the Routine Uses for the system can be found in the System of Records Notice State-59, Refugee Case Records. DISCLOSURE: Providing this information is voluntary. Failure to provide the information requested on this form may result in denied consideration for your relative's access to the USRAP for refugee resettlement.
Paperwork Reduction Act Public reporting burden for this collection of information is estimated to average 90 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: U.S. Department of State, A/GIS/IPS, 2025 E Street, NW Washington DC, 20520. OMB No. 1405-0206.

SECTION II: Information about the Qualifying Family Member seeking access to the USRAP and their Relatives
01. Qualifying Family Member (QFM): Only a parent, a spouse, or an unmarried child under age 21 can be claimed as a QFM
Name (Last, First, Middle)						Date of Birth (e.g. 05 JAN 2010)
Gender (Male, Female, or X)		Marital Status			Preferred Language
City and Country of Birth		Nationality			Relationship to U.S.-Based Family Member
Current Location City ___________________________________ State/Province __________________________ Country _______________________________
Preferred Phone Number		Alternate Phone Number (if provided)			E-mail Address
Current Spouse’s Name (Last, First, Middle)		Date of Marriage (e.g. 05 JAN 2010)			Place of Marriage
Previous Spouse’s Name	Date of Marriage		Place of Marriage	Date of Termination			Place of Termination
Previous Spouse’s Name	Date of Marriage		Place of Marriage	Date of Termination			Place of Termination
Previous Spouse’s Name	Date of Marriage		Place of Marriage	Date of Termination			Place of Termination

	02-16. Relatives: Enter type “B” for the QFM’s spouse and any unmarried children under age 21 or “C” for members of same economic unit
Type	#	Name (Last, First, Middle)			Gender	Date of Birth	Father’s Name	Mother’s Name	City and Country of Birth	Nationality	Marital Status	Relationship to QFM
	02
	03
	04
	05
	06
	07
	08
	09
	10
	11
	12
	13
	14
	15
	16

ADD ADDITIONAL PAGES, AS NEEDED, FOR EACH ADDITIONAL QUALIFYING FAMILY MEMBER BEING CLAIMED

SECTION III: Photos of the Qualifying Family Member and their relatives from Section II

01 - Qualifying Family Member		02		03		04
Name		Name		Name		Name
DOB		DOB		DOB		DOB
Rel to USBFM		Rel to QFM		Rel to QFM		Rel to QFM

05		06		07		08
Name		Name		Name		Name
DOB		DOB		DOB		DOB
Rel to QFM		Rel to QFM		Rel to QFM		Rel to QFM

09		10		11		12
Name		Name		Name		Name
DOB		DOB		DOB		DOB
Rel to QFM		Rel to QFM		Rel to QFM		Rel to QFM

13		14		15		16
Name		Name		Name		Name
DOB		DOB		DOB		DOB
Rel to QFM		Rel to QFM		Rel to QFM		Rel to QFM

SECTION IV: Additions / Explanations (Identify for which section, number, and name the information is being provided)

SECTION V: Signatures
The U.S.-Based Family Member’s name and signature
I certify, under penalty of perjury under the laws of the United States of America, that all of the foregoing information given in this Affidavit of Relationship is true and correct to the best of my knowledge. I understand that the information listed in this Affidavit of Relationship may be used by the U.S. Department of State and the U.S. Department of Homeland Security in the manner described in the Privacy Act statement. By submitting this Affidavit of Relationship, I understand that I and the individual(s) listed above as Qualifying Family Member(s) (parent(s) or unmarried child(ren) under age 21) may be required to submit DNA evidence to verify our claimed family relationships. I agree that I will submit DNA evidence at such time it is requested by an official of the U.S. government or its designated representative, and I understand that the Qualifying Family Member(s) may not be considered qualified to apply for refugee resettlement if I, or they, fail to submit DNA evidence upon request. I further understand that following the USCIS interview, the U.S. government or its designated representative may suggest DNA testing for my Qualifying Family Member(s) and any derivative applicant(s) (unmarried child(ren) under the age of 21), at no expense to the U.S. government, if they are unable to prove the existence of the claimed family relationship. Failure to submit the suggested DNA evidence may result in the derivative applicant(s) being considered ineligible for resettlement.
Signature	Print Name	Date (e.g. 05 JAN 2010)

Name and signature of the person who assisted in preparing this form
I affirm that I assisted the U.S.-based family member listed above in completing this form and that the U.S.-based family member listed above provided valid identification issued by a U.S. federal or state agency.
Signature	Print Name		Date (e.g. 05 JAN 2010)
Affiliate Name & Address		Phone Number

Form DS-7656 Instructions (11-2024) Page 7 of 5