Pages 3-4,
Part
2. Obligor's or Agent/Co-Obligor's Statement, Contact
Information, Certification, and Signature (To
Be Completed By the Obligor or Agent/Co-Obligor)
|
[Page 3]
Part 2. Obligor's or
Agent/Co-Obligor's Statement, Contact Information, Certification,
and Signature (To Be Completed By the Obligor or
Agent/Co-Obligor)
1.Choose the appropriate
statement and sign.
[ ] A. The Alien Naturalized,
Permanently Departed the United States, or Died
I (Name of the Obligor) __________,
or I (Name of the Agent/Co-Obligor) __________, acting on behalf
of (Name of the Obligor) __________, request that the public
charge bond executed on Form I-945 on behalf of (Name of the
Alien) __________, born on (Alien Date of Birth (mm/dd/yyyy))
__________, and residing at (Address of the Alien) __________, be
cancelled and that (Name of the Obligor) __________, and (Name of
the Agent/Co-Obligor, if any) __________, be released from all
liabilities imposed by the conditions of the bond because the
alien either naturalized, permanently departed the United States,
or died, and the conditions of the bond, as outlined in 8 CFR
213.1 are otherwise met, including that the alien has not received
any public benefits, as defined in 8 CFR 212.21(b) for more than
12 months in the aggregate within any 36 month period (such that,
for instance, receipt of two benefits in one month counts as two
months), after the alien's adjustment of status to that of a
lawful permanent resident and until this bond is cancelled.
[ ] B. Cancellation Following The
Alien's 5th Anniversary of the Alien's Admission as a Lawful
Permanent Resident
I (Name of the Obligor) __________,
or I (Name of the Agent/Co-Obligor) __________, acting on behalf
of (Name of the Obligor) __________, request that the public
charge bond executed on Form I-945 on behalf of (Name of the
Alien) __________, born on (Alien Date of Birth (mm/dd/yyyy))
__________, and residing at (Address of the Alien) __________, be
cancelled because it is past the alien's fifth anniversary of the
admission as a lawful permanent resident and the conditions of the
bond, as outlined in 8 CFR 213.1, are otherwise met, including
that the alien has not received public benefits, as defined in 8
CFR 212.21(b) for more than 12 months in the aggregate within any
36 month period (such that, for instance, receipt of two benefits
in one month counts as two months), since the alien's adjustment
of status to that of a lawful permanent resident and preceding the
5th anniversary of the Alien's Adjustment of Status.
[ ] C. The Alien Obtained An
Immigration Status That is Exempt From Public Charge Grounds of
Inadmissibility under INA section 212(a)(4)Following the Initial
Grant of Lawful Permanent Resident Status
I (Name of the Obligor) __________,
or I (Name of the Agent/Co-Obligor) __________, acting on behalf
of (Name of the Obligor) __________, request that the public
charge bond executed on Form I-945 on behalf of (Name of the
Alien) __________, born on (Alien Date of Birth (mm/dd/yyyy))
__________, and residing at (Address of the Alien) __________, be
cancelled and that (Name of the Obligor) __________ and (Name of
Agent/Co-obligor, if any) __________
[Page 4]
be released from all liabilities
imposed by the conditions of the bond because the alien has
obtained an immigration status that is exempt from public
charge grounds of inadmissibility under INA section 212(a)(4),
following the initial grant of the alien's adjustment of status to
that of a lawful permanent resident, and the conditions of the
bond, as outlined in 8 CFR 213.1, are otherwise met, including
that the alien has not received public benefits, as defined in 8
CFR 212.21(b) for more than 12 months in the aggregate within any
36 month period (such that, for instance, receipt of two benefits
in one month counts as two months), after the alien's adjustment
of status to that of a lawful permanent resident and until he or
she obtained the new status that is exempt from public charge.
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 whether the conditions of the bond are
met and that the bond can be cancelled. I furthermore authorize
release of information contained in this form, in supporting
documents, and in 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 all of the information in Parts 1. and 2. of this Form
I-356 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, Parts 1. and 2.
of Form I-356, and that all of this information is complete, true,
and correct.
2. Signature of Obligor
Date of Signature (mm/dd/yyyy)
3. Signature of
Agent/Co-Obligor (if any)
Date of Signature (mm/dd/yyyy)
|
[Page 3]
Part 2. Obligor's or
Agent/Co-Obligor's Contact
Information, Certification, and Signature (To Be
Completed By the Obligor or Agent/Co-Obligor)
1. Choose the appropriate
statement and sign.
[ ] A. The Alien Naturalized,
Permanently Departed the United States, or Died
I (Name of the Obligor) __________,
or I (Name of the Agent/Co-Obligor) __________, acting on behalf
of (Name of the Obligor) __________, request that the public
charge bond executed on Form I-945 on behalf of (Name of the
Alien) __________, born on (Alien Date of Birth (mm/dd/yyyy))
__________, and residing at (Address of the Alien) __________, be
cancelled and that (Name of the Obligor) __________, and (Name of
the Agent/Co-Obligor, if any) __________, be released from all
liabilities imposed by the conditions of the bond because the
alien did not breach the bond pursuant to 8
CFR 103.6(c)(1)(B), complied with all conditions of the
bond, and either naturalized, permanently
departed the United States, or died.
[ ] B. Cancellation Following the
5th Anniversary of the Alien
Becoming a Lawful Permanent Resident
I (Name of the Obligor) __________,
or I (Name of the Agent/Co-Obligor) __________, acting on behalf
of (Name of the Obligor) __________, request that the public
charge bond executed on Form I-945 on behalf of (Name of the
Alien) __________, born on (Alien Date of Birth (mm/dd/yyyy))
__________, and residing at (Address of the Alien) __________, be
cancelled and that (Name of the Obligor)
__________, and (Name of the Agent/Co-Obligor, if any) __________,
be released from all liabilities imposed by the conditions
of the bond, because it is past the fifth
anniversary of the alien becoming a lawful permanent resident, the
alien complied with all conditions of the bond, and the alien did
not breach the bond pursuant to 8 CFR 103.6(c)(1)(B) before the
fifth anniversary of becoming a lawful permanent resident.
[delete]
[no change]
|
Pages 5-7,
Part
4. Reason for Cancellation of the Bond
|
[Page 5]
Part 4. Reason for Cancellation
of the Bond
1. I am requesting a
cancellation because:
[ ] I became a U.S. Citizen (answer
Item Number 2.)
[ ] I permanently departed the
United States (answer Item Number 3.)
[ ] The alien is deceased and I am
the alien's executor (answer Item Number 4.)
[ ] Five years have passed since I
became a lawful permanent resident (answer Item Number 5.)
…
[Page 6]
Permanently Departed the
United States
3. Have you permanently
departed the United States? Provided documentation as provided in
the Instructions.
[ ] Yes, I departed and submitted
Form I-407 to the U.S. Government from outside the United States
to record the abandonment of my lawful permanent residence.
[ ] Yes, I departed after I was
granted voluntary departure (under INA 240B).
[ ] Yes, I departed after I received
a final order of removal, exclusion or deportation (self-removed).
[ ] Yes, I was physically removed
from the United States after I received a final order of removal,
exclusion or deportation.
[ ] No, I have not permanently
departed. (Go to Item Number 4.)
If you answered “Yes,”
please provide the following information (as applicable) in Items.
A. - D.
A. Date you left the United
States (mm/dd/yyyy)
B. Place of
Departure/Removal, Exclusion, or Disposition
C. Date When Record of
Abandonment of Lawful Permanent Resident Status (Form I-407) was
filed (mm/dd/yyyy)
D. Place where Form I-407
(USCIS International Office, U.S. Embassy/Consular Section/ Port
of Entry) was filed
E. Date of the Removal,
Exclusion, Deportation, or Voluntary Departure Order (mm/dd/yyyy)
Deceased
4. Has the alien on whose
behalf a bond has been issued died?
Yes
No (Go to Item Number 5.)
If you answered “No,” go
to Item Number 5. If you answered “Yes,”
please provide the information in Items A. - B. about the
alien's death and attach a certified copy of the alien's death
certificate:
A. Date of Death (mm/dd/yyyy)
B. Death Certificate Number
(please attach an official copy of the death certificate)
…
[Page 7]
Five Years after Becoming a
Lawful Permanent Resident
5. Have you been a lawful
permanent resident for at least five years?
Yes
No
If you answered “Yes,”
please provide the information about when you became a lawful
permanent resident below.
Date When You Became a Lawful
Permanent Resident (mm/dd/yyyy)
|
[Page 5]
Part 4. Reason for Cancellation
of the Bond
1. I am requesting a
cancellation because:
[ ] I became a U.S. citizen (answer
Item Number 2.).
[ ] I permanently departed the
United States (answer Item Number 3.).
[ ] The alien is deceased and I am
the executor of the alien’s estate
(answer Item Number 4.).
[ ] Five years have passed since I
became a lawful permanent resident (answer Item Number 5.).
…
Permanently Departed the
United States
3. Have you permanently
departed the United States? Please provide
documentation.
Yes
[delete]
No, I have not permanently departed
the United States. (Go to Item Number 4.)
If you answered “Yes,”
please provide the following information (as applicable) in Items.
A. - E.
[no change]
D. Place Where
Form I-407 (USCIS International Office, U.S.
Embassy/Consular Section/Port of Entry) Was
Filed
[no change]
[Page 6]
A. Date of Alien’s
Death (mm/dd/yyyy)
B. Death Certificate Number
(please attach an official copy of the death certificate)
…
[Page 7]
Five Years After
Becoming a Lawful Permanent Resident
5. Have you been a lawful
permanent resident for at least five years?
Yes
No
If you answered “Yes,”
please provide the information about when you became a lawful
permanent resident below.
Date When You Became a Lawful
Permanent Resident (mm/dd/yyyy)
Receipt
of Public Benefits
6.
Has the alien received any means-tested public benefit before the
event that forms the basis for the cancellation request (the fifth
anniversary of becoming a lawful permanent resident, the date the
alien became a United States citizen, , the date the alien
permanently departing the United States, or the date of the
alien’s death, whichever is applicable)?
Yes
No
If you
answered “Yes,” please provide information about which
means-tested public benefit(s) you received and when, including
the source that provided the benefit (the Federal, or a specific
State, territorial, tribal, or local government or government
agency).
|
Pages 7-9,
Part
5. Alien's Receipt of Public Benefits since DHS' Acceptance of
the Public Charge Bond (To
be Completed by the Alien or the Alien's Executor (if the Alien is
Deceased))
|
[Page 7]
Part 5. Alien's Receipt of
Public Benefits since DHS' Acceptance of the Public Charge Bond
(To be Completed by the Alien or the Alien's Executor (if the
Alien is Deceased))
Please provide the following
information about your (the alien's) receipt of public benefits
since you were granted adjustment of status to that of a lawful
permanent resident. See the Instructions for a definition of
public benefits.
1. Since you were granted
adjustment of status to that of a lawful permanent resident, have
you received or are currently certified to receive in the future
the following public benefits for more than 12 months in the
aggregate within any 36 month period?
Yes
No
[ ] Yes, I have received, or I am
currently certified to receive in the future the following
benefits:
[ ] Any Federal,
State, local or tribal cash assistance for income maintenance
[ ] Supplemental
Security Income (SSI)
[ ] Temporary
Assistance for Needy Families (TANF)
[ ] General
Assistance (GA)
[ ] Supplemental
Nutrition Assistance Program (SNAP, formerly called "Food
Stamps")
[ ] Section 8
Housing Assistance under the Housing Choice Voucher Program
[ ] Section 8
Project-Based Rental Assistance (including Moderate
Rehabilitation)
[ ] Public
Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.
[ ]
Federal-funded Medicaid
[ ] No, I have not received any
public benefits.
[ ] No, I am not certified to
receive in the future any of the above public benefits.
[Page 8]
2. If you received any of the
above public benefits, provide information about the receipt of
public benefits in the space provided. If you need additional
space to complete any Item Number in this Part, use the space
provided in Part 9. Additional Information. Submit evidence
as outlined in the instructions.
A. Type of Public Benefit
Agency That Granted The Benefit
Date you were Authorized to Start
Receiving the Benefit or Date Your Coverage Starts (mm/dd/yyyy)
Date Benefit or Coverage Ended or
Expires or Expected to Expire (mm/dd/yyyy)
B. Type of Public Benefit
Agency That Granted The Benefit
Date you were Authorized to Start
Receiving the Benefit or Date Your Coverage Starts (mm/dd/yyyy)
Date Benefit or Coverage Ended or
Expires or Expected to Expire (mm/dd/yyyy)
C. Type of Public Benefit
Agency That Granted The Benefit
Date you were Authorized to Start
Receiving the Benefit or Date Your Coverage Starts (mm/dd/yyyy)
Date Benefit or Coverage Ended or
Expires or Expected to Expire (mm/dd/yyyy)
Public Benefit Exemptions
3. If you answered “Yes”
to Item Number 1., check any box that is applicable to you
and provide the evidence listed in the Form I-356 Instructions if
any of the following apply to you.
[ ] I am enlisted in the Armed
Forces, or am serving in active duty or in the Ready Reserve
Component of the U.S. Armed Forces.
[ ] I am the spouse or the child of
an individual who is enlisted in the Armed Forces, or is serving
in active duty or in the Ready Reserve Component of the U.S. Armed
Forces.
[ ] At the time I received the
public benefits, I (or my spouse or parent) __________ was
enlisted in the Armed Forces, or was serving in active duty or in
the Ready Reserve Component of the U.S. Armed Forces.
[Page 9]
[ ] At the time I received the
public benefits, I was present in the United States in a status
exempt from the public charge ground of inadmissibility and I
received the public benefits during that time.
[ ] At the time I received the
public benefits, I was present in the United States after being
granted a waiver from the public charge ground of inadmissibility
and received the public benefits during that time.
[ ] At the time I received the
benefits, I was a child of U.S. citizens whose lawful admission
for permanent residence and subsequent residence in the legal and
physical custody of my U.S. citizen parent would result in me
automatically acquiring U.S. citizenship upon meeting the
eligibility under INA 320 or the child of U.S. citizens whose
lawful admission for permanent residence will result automatically
in my acquisition of citizenship upon finalization of adoption
(and I satisfied the requirements applicable to adopted children
under INA 101(b)(1)), in the United States by the U.S. citizen
parent(s), upon meeting the eligibility criteria under INA 320; or
I was a child residing abroad who entered the United States with a
nonimmigrant visa to attend an N-600K, Application for Citizenship
and Issuance of Certificate Under INA Section 322 interview.
[ ] None of the above statements
apply to me.
4. Have you received
federal-funded Medicaid in connection with any of the following
(select all that apply): Submit evidence as outlined in the
Instructions.
[ ] An emergency medical condition.
[ ] For a service under the
Individuals with Disabilities Education Act (IDEA).
[ ] Other school-based benefits or
services available up to the oldest age eligible for secondary
education under State law.
[ ] While you were under the age of
21.
[ ] While you were pregnant or
during the 60-day period following the last day of pregnancy.
[ ] None of the above apply to me.
A. Provide the applicable
dates (mm/dd/yyyy)
|
[delete]
|
Pages 9-11,
Part
6. Alien's (or Alien Executor's) Contact Information,
Certification, and Signature
|
[Page 9]
Part 6. Alien's (or Alien
Executor's) Contact Information, Certification, and Signature
NOTE: Read the Penalties
section of the Form I-356 Instructions before completing this
section.
Alien's (or the Alien's
Executor'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. Alien's (or the Alien's
Executor's) Statement Regarding the Interpreter
A. I can read and understand
English, and I have read and understand every question and
instruction in my portion of Form I-356 and my answer to every
question.
B. The interpreter named in
Part 7. read to me every question and instruction in my
portion of the Form I-356 and my answer to every question in
___________, a language in which I am fluent, and I understood
everything.
[Page 10]
2. Alien's (or the Alien's
Executor's) Statement Regarding the Preparer
[ ] At my request, the preparer
named in Part 8., _______, prepared my parts of this Form
I-356 for me based only upon information I provided or authorized.
Alien's (or the Alien's
Executor's) Contact Information
3. Daytime Telephone Number
4. Mobile Telephone Number
(if any)
5. Email Address (if any)
Federal Agency Disclosure and
Authorizations
I _______, authorize, as applicable,
the Social Security Administration (SSA) to verify my/the alien's
Social Security number (to match my name, Social Security number,
and date of birth with information in SSA records and provide the
results of the match) to USCIS. I (the alien/the alien's executor)
authorize SSA to provide explanatory information to USCIS as
necessary.
I _______, authorize, as applicable,
the SSA, U.S. Department of Agriculture (USDA), and U.S.
Department of Health and Human Services (HHS), the Department of
Housing and Urban Development (HUD), and any other government
agency that has received and/or adjudicated a request for a public
benefit, as defined in 8 CFR 212.21(b) submitted by me/the alien
or on my/the alien's behalf, and/or granted one or more public
benefits to me/the alien to disclose to USCIS that I (the
alien/alien's executor) have applied for, received, or have been
certified to receive, a public benefit from such agency, including
the type and amount of benefit(s), date(s) of receipt and any
other relevant information provided to the agency for the purpose
of obtaining such public benefit, to the extent permitted by law.
I (the alien/the alien's executor) also authorize SSA, USDA, HHS,
HUD, and any other government agency to provide any additional
data and information to USCIS, to the extent permitted by law.
I _______, authorize, as applicable,
custodians of records and other sources of information pertaining
to my/the alien's request for or receipt of public benefits to
release information regarding my/the alien's request for and/or
receipt of public benefits, upon the request of the investigator,
special agent, or other duly accredited representative of any
federal agency authorized above, regardless of any previous
agreement to the contrary.
I _______, as applicable, understand
that the information released by records custodians and sources of
information is for official use by the federal government, that
the government will use it only to review my/the alien's
eligibility for immigration benefits and to enforce immigration
laws, and that the government may disclose the information only as
authorized by law.
Alien's (or Alien's
Executor's) 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 whether the bond should be cancelled.
I furthermore authorize release of
information contained in this form, in supporting documents, and
in my/the alien's USCIS records, to other entities and persons
where necessary for the administration and enforcement of U.S.
immigration law.
[Page 11]
Alien's (or Alien's
Executor's) Signature
6. Alien's (or Alien's
Executor's) Signature
Date of Signature (mm/dd/yyyy)
NOTE to Aliens (or Alien's
Executor): If you do not completely fill out your parts of
Form I-356 or fail to submit required documents listed in the
Instructions, USCIS may deny the request to cancel the bond.
|
[Page 7]
Part 5.
Alien's (or Alien Executor's) Contact Information, Certification,
and Signature
[delete]
Alien's (or the Alien's
Executor's) Contact Information
1. Daytime
Telephone Number
2. Mobile
Telephone Number (if any)
3. Email
Address (if any)
Federal Agency Disclosure and
Authorizations
I _______, authorize, as applicable,
the Social Security Administration (SSA) to verify my/the alien's
Social Security number (to match my name, Social Security number,
and date of birth with information in SSA records and provide the
results of the match) to USCIS. I (the alien/the alien's
executor) authorize SSA to provide explanatory information to
USCIS as necessary.
[delete]
I _______,
as applicable, understand that the information released by records
custodians and sources of information is for official use by the
Federal government, that the government will use it only to review
my/the alien's eligibility for immigration benefits and to enforce
immigration laws, and that the government may disclose the
information only as authorized by law.
Alien's (or Alien's
Executor's) Certification and
Signature
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 whether the bond should be cancelled.
I furthermore authorize release of
information contained in this form, in supporting documents, and
in my/the alien's USCIS records, to other entities and persons
where necessary for the administration and enforcement of U.S.
immigration law.
[delete]
4. Alien's
(or Alien's Executor's) Signature
Date of Signature (mm/dd/yyyy)
[delete]
|
Pages 11-12,
Part
7. Interpreter's Contact Information, Certification, and
Signature
|
[Page 11]
Part 7. Interpreter's
Contact Information, Certification, and Signature
Provide the following information
about 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 ________,
which is the same language provided in Part 6., Item
B. in Item Number 1., and I have read to this alien or
the alien's executor in the identified language every question and
instruction on the alien's parts of Form I-356 and his or her
answer to every question. The alien or the alien's executor
informed me that he or she understands every instruction,
question, and answer in the alien's parts of Form I-356, including
the Alien (or the Alien's Executor's) Certification, and
has verified the accuracy of every answer.
[Page 12]
Interpreter's Signature
7. Interpreter's Signature
Date of Signature (mm/dd/yyyy)
|
[Page 8]
Part 6.
Interpreter's Contact Information, Certification,
and Signature
[delete]
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)
[delete]
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 Form
I-356 and Instructions
and interpreted the alien
or the alien's executor’s
answers to the questions in that language, and the alien
or the alien's executor
informed
me that he
or she understood
every instruction, question, and answer on the Form I-356.
[delete]
6.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)
|
Pages 12-13,
Part
8. Contact Information, Certification, and Signature of the
Person Preparing the Alien's Parts of Form I-356, if Other Than
the Alien (or the Alien's Executor)
|
[Page 12]
Part 8. Contact
Information, Certification, and Signature of the Person Preparing
the Alien's Parts of Form I-356, if Other Than the Alien (or the
Alien's Executor)
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. Preparer's Email Address
(if any)
Preparer's Statement
7.A. I am not an attorney or
accredited representative but have prepared the alien's part of
this form on behalf of the alien or the alien's executor and with
the alien's or the alien's executor's consent.
B. I am an attorney or
accredited representative and my representation of the alien or
the alien's executor in this case extends/does not extend beyond
the preparation of this 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, with this Form.
[Page 13]
Preparer's Certification
By my signature, I certify, under
penalty of perjury, that I prepared the alien's parts of this form
at the request of the alien or the alien's executor. The alien or
the alien's executor then reviewed these completed parts of this
form and informed me that he or she understands all of the
information contained in, and submitted with, the alien's parts of
Form I-356, including the Alien's (or the Alien's Executor's)
Certification, and that all of this information is complete,
true, and correct. I completed the alien's parts of the form
based only on information that the alien or the alien's executor
provided to me or authorized me to obtain or use.
Preparer's Signature
8.Preparer's Signature
Date of Signature (mm/dd/yyyy)
|
[Page 8]
Part
7. Contact
Information, Declaration,
and Signature of the Person Preparing the Alien's
Parts of Form I-356, if Other Than the Alien (or the Alien's
Executor)
[delete]
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)
[delete]
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)
[delete]
[Page 9]
Preparer's Certification and
Signature
I
certify, under penalty of perjury, that I prepared
this request for the
alien or the alien's executor
at their request and with express consent and that all of the
responses and information
contained in
and submitted
with
the request are complete,
true, and correct
and reflects only information provided by the alien or the alien's
executor. The alien or the alien's executor reviewed the
responses and information and
informed me that they understand the responses and information in
or submitted with the request.
[delete]
6.
Preparer's Signature
Date of Signature (mm/dd/yyyy)
|