Form I-694 Form I-694 Notice of Appeal of Decision Under Section 210 or 245A

Notice of Appeal of Decision Under INA Section 210 or 245A

USCIS
Form I-694

Department of Homeland Security
U.S. Citizenship and Immigration Services
Action Block

OMB No. 1615-0034
Expires: 12/31/2015

Fee Stamp

For
USCIS
Use
Only

► START HERE - Type or print in black ink.

Part 1. Information About You (Appellant)
1.

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Full Legal Name

Family Name (Last Name)

2.

3.

Given Name (First Name)

Middle Name

A. Family Name (Last Name)

Given Name (First Name)

Middle Name

B. Family Name (Last Name)

Given Name (First Name)

Middle Name

Any Other Names Used

U.S. Mailing Address
In Care Of Name

4.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Is your current U.S. mailing address the same as your U.S. physical address?

ZIP Code

Yes

No

If you answered "No," provide your U.S. physical address in Item Number 5.
5.

6.

8.

U.S. Physical Address

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Alien Registration Number (A-Number) (if any)
► A-

7.

ZIP Code

U.S. Social Security Number (if any)
►

USCIS Online Account Number (if any)
►

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Part 2. Application Information
1.

Your appeal is based on an application for which of the following?
Permanent Residence
(Form I-698)

2.

Receipt Number (if any)

Temporary Residence
(Form I-687)
3.

Waiver of Grounds of Inadmissibility
(Form I-690)

Date of Decision (mm/dd/yyyy)

Part 3. Reason for Appeal
1.

Yes

Is your written brief attached?

No

If you answered "No," select a response in Item Number 2.
2.

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I waive the right to submit a written brief or statement.

I will submit a brief within 30 calendar days.

The appeal must include a statement explaining any error or conclusion of law in the decision being appealed or any erroneous
statement of fact stated in the decision. Please provide an explanation. If you need additional space to complete this section, use
the space provided in Part 7. Additional Information.

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Part 4. Appellant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-694 Instructions before completing this part.

Appellant's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Appellant's Statement Regarding the Interpreter
A.

I can read and understand English, and I have read and understand every question and instruction on this form and my
answer to every question.

B.

The interpreter named in Part 5. read to me every question and instruction on this form and my answer to
every question in

, a language in which

I am fluent and I understood everything.
2.

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Appellant's Statement Regarding the Preparer

At my request, the preparer named in Part 6.,
prepared this form for me based only upon information I provided or authorized.

Appellant's Contact Information
3.

Appellant's Daytime Telephone Number

5.

Appellant's Email Address (if any)

4.

Appellant's Mobile Telephone Number (if any)

Appellant'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 of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I certify, under penalty of perjury, that I provided or authorized all of the information in this form, I understand all of the information
contained in, and submitted with, this form, and that all of this information is complete, true, and correct.

Appellant's Signature
6.

Appellant's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL APPELLANTS: If you do not completely fill out this form or fail to submit required documents listed in the
Instructions, USCIS may deny your benefit.

Part 5. 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)

2.

Interpreter's Business or Organization Name (if any)

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Interpreter's Given Name (First Name)

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Part 5. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information

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4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (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 4., Item B. in Item Number 1., and I have read to this appellant in the identified language every question and instruction on
this form and his or her answer to every question. The appellant informed me that he or she understands every instruction, question,
and answer on the form, including the Appellant's Certification, and has verified the accuracy of every answer.

Interpreter's Signature
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 6. Contact Information, Declaration, and Signature of the Person Preparing This Form, if Other
Than the Appellant
Provide the following information about the preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization (if any)

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Preparer's Given Name (First Name)

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Part 6. Contact Information, Declaration, and Signature of the Person Preparing This Form, if Other
Than the Appellant (continued)
Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

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Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this form on behalf of the
appellant and with the appellant's consent.

B.

I am an attorney or accredited representative and my representation of the appellant in this case
extends
does not extend beyond the preparation of this form.

NOTE: If you are an attorney or accredited representative whose representation extends beyond
preparation of this form, you may be obliged to submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited Representative, with this form.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this form at the request of the appellant. The appellant then
reviewed this completed form and informed me that he or she understands all of the information contained in, and submitted with, his
or her form, including the Appellant's Certification, and that all of this information is complete, true, and correct. I completed this
form based only on information that the appellant provided to me or authorized me to obtain or use.

Preparer's Signature
Preparer's Signature

Date of Signature (mm/dd/yyyy)

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8.

Part 7. Additional Information
If you need extra space to provide any additional information within this form, use the space below. If you need more space than what
is provided, you may make copies of this page to complete and file with this form or attach a separate sheet of paper. Type or print
your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which
your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any)

3.

A. Page Number

D.

4.

5.

A. Page Number

D.

6.

Middle Name

► AB. Part Number

C. Item Number

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A. Page Number

D.

Given Name (First Name)

A. Page Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

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