Page 1,
Part 1. Information About You
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1. Alien Registration Number
(A-Number)(if any)
2. USCIS ELIS Account Number (if
any)
Your Full Name
3.a. Family Name (Last Name)
3.b. First Name (Given Name)
3.c. Middle Name
Provide other names you have
used, including maiden name, aliases, and tribal names.
4.a. Family Name (Last Name)
4.b. First Name (Given Name)
4.c. Middle Name
5.a. Family Name (Last Name)
5.b. First Name (Given Name)
5.c. Middle Name
Your Mailing Address
6.a.
Street Number and Name
6.b.
[ ] Apt. [ ] Ste. [ ] Flr. [fillable field]
6.c.
City or Town
6.d.
State
6.e.
ZIP Code
6.f.
Province
6.g.
Postal Code
6.h.
Country
If you are currently living
abroad, enter your last address in the United States.
7.a.
Street Number and Name
7.b.
[ ] Apt. [ ] Ste. [ ] Flr. [fillable field]
7.c.
City or Town
7.d.
State
7.e.
ZIP Code
Other
Information
8.
Date of Birth (mm/dd/yyyy)
9.
City/Town/Village of Birth
10.
Country of Birth
11.
Country of Citizenship or Nationality
12.
Country of Last Foreign Residence
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[Page 1]
Part 1. Information About You
1. Alien Registration Number
(A-Number)(if any)
2. USCIS Online
Account Number (if any)
[No Change]
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Page 5,
Part 5. Applicant's Statement,
Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature
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Part 5. Applicant's Statement,
Contact Information, Acknowledgement of Appointment at USCIS
Application Support Center, Certification, and Signature
NOTE: Read the information
on penalties in the Penalties section of the Form I-612
Instructions before completing this part.
Applicant's Statement
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 have read and understand every question
and instruction on this application, as well as my answer to every
question. I have read and understand the Acknowledgement of
Appointment at USCIS Application Support Center.
1.b. The interpreter named in
Part 6. has read to me every question and instruction on
this application, as well as my answer to each question, in
[fillable field], a language in which I am fluent. I
understand every question and instruction on this application as
translated to me by my interpreter, and have provided complete,
true, and correct responses in the language indicated above. The
interpreter named in Part 6. has also read the
Acknowledgement of Appointment at USCIS Application Support
Center to me, in the language in which I am fluent, and I
understand this Application Support Center (ASC) Acknowledgement
as read to me by my interpreter.
2. I have requested the
services of and consented to [fillable field], who
is/is not an attorney or accredited representative,
preparing this application for me. This person who assisted me in
preparing my application has reviewed the Acknowledgement of
Appointment at USCIS Application Support Center with me, and I
understand the ASC Acknowledgement.
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)
Acknowledgement of Appointment
at USCIS Application Support Center
I, [fillable field],
understand that the purpose of a USCIS ASC appointment is for
me to provide my fingerprints, photograph, and/or signature and to
re-affirm that all of the information in my application is
complete, true, and correct and was provided by me. I understand
that I will sign my name to the following declaration which USCIS
will display to me at the time I provide my fingerprints,
photograph, and/or signature during my ASC appointment:
understand that the purpose of a USCIS ASC appointment is for
me to provide my fingerprints, photograph, and/or signature and to
re-affirm that all of the information in my application is
complete, true, and correct and was provided by me. I understand
that I will sign my name to the following declaration which USCIS
will display to me at the time I provide my fingerprints,
photograph, and/or signature during my ASC appointment:
By signing here, I declare
under penalty of perjury that I have reviewed and understand my
application, petition, or request as identified by the receipt
number displayed on the screen above, and all supporting
documents, applications, petitions, or requests filed with my
application, petition, or request that I (or my attorney or
accredited representative) filed with USCIS, and that all of the
information in these materials is complete, true, and correct.
I also understand that when I sign
my name, provide my fingerprints, and am photographed at the USCIS
ASC, I will be re-affirming that I willingly submit this
application; I have reviewed the contents of this application; all
of the information in my application were provided by me and all
supporting documents submitted with my application are complete,
true, and correct; and if I was assisted in completing this
application, the person assisting me also reviewed this
Acknowledgement of Appointment at USCIS Application Support
Center with me.
Applicant'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 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 USCIS records to other entities and persons
where necessary for the administration and enforcement of U.S.
immigration laws.
I certify, under penalty of perjury,
that under the laws of the United States of America, that the
information in my application and any document submitted with my
application were provided by me and are complete, true, and
correct.
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.
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[Page 5]
Part 5.
Applicant’s Statement,
Contact Information, Certification, and Signature
NOTE:
Read the Penalties
section of the Form I-612 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 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 Filed], 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)
[Delete]
[Delete]
[Delete]
Applicant’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 further
authorize 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 laws.
I
certify, under penalty of perjury, that I provided or authorized
all of the information in my application,
I 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
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.
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Page 6,
Part 6. Interpreter's Contact
Information, Certification, and Signature
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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)
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 Email
Address (if any)
Interpreter's Certification
I certify that:
I am fluent in English and [fillable
field], which is the same language provided in Part
5., Item Number 1.b.;
I have read to this applicant every
question and instruction on this application, as well as the
answer to every question, in the language provided in Part 5.,
Item Number 1.b.;
I have read the Acknowledgement
of Appointment at USCIS Application Support Center to the
applicant in the same language provided in Part 5., Item
Number 1.b.
The applicant has informed me that
he or she understands every instruction and question on the
application, as well as the answer to every question, and the
applicant verified the accuracy of every answer; and
The applicant has also informed me
that he or she understands the ASC Acknowledgement and that by
appearing for a USCIS ASC biometric services appointment and
providing his or her fingerprints, photograph, and/or signature,
he or she is re-affirming that the contents of this application
and all supporting documentation are complete, true, and correct.
Interpreter's Signature
6.a. Interpreter's Signature
6.b. Date of Signature
(mm/dd/yyyy)
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[Page 6]
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)
Interpreter’s
Mailing Address
3.a.
Street Number and Name
3.b.
[ ] Apt. [ ] Ste. [ ] Flr. [fillable field]
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 [Sub-header]
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
Certification, and has verified
the accuracy of every answer.
[Delete]
[Delete]
Interpreter’s
Signature
7.a.
Interpreter’s Signature
7.b.
Date of Signature (mm/dd/yyyy)
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Page 7,
Part 7. Contact Information, Statement, Certification, and
Signature of the Person Preparing this Application, If Other Than
the Applicant
|
Provide the following information
concerning 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 Fax Number
6. Preparer's Email Address
(if any)
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 whose representation extends beyond
preparation of this application you must submit a completed Form
G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, with this application.
Preparer's Certification
By my signature, I certify, swear,
or affirm, under penalty of perjury, that I prepared this
application on behalf of, at the request of, and with the express
consent of the applicant. I completed this application based only
on responses the applicant provided to me. After completing the
application, I reviewed it and all of the applicant's responses
with the applicant, who agreed with every answer on the
application. If the applicant supplied additional information
concerning a question on the application, I recorded it on the
application. I have also read the Acknowledgement of
Appointment at USCIS Application Support Center to the
applicant and the applicant has informed me that he or she
understands the ASC Acknowledgement.
Preparer's Signature
8.a. Preparer's Signature
8.b. Date of Signature
(mm/dd/yyyy)
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[Page 7]
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. [fillable field]
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)
Preparer's
Statement
7.a.
I am not an attorney or accredited representative but have
prepared this form on behalf of the authorized individual and with
the authorized individual's consent.
7.b.
I am an attorney or accredited representative and have prepared
this form on behalf of the authorized individual and with the
authorized individual’s consent.
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
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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