Form I-526 Immigrant Petition by Alien Entrepreneur

Immigrant Petition by Alien Entrepreneur

USCIS
Form I-526

Department of Homeland Security
U.S. Citizenship and Immigration Services
Classification

Fee Receipt

For
USCIS
Use
Only

OMB No. 1615-0026
Expires 09/30/2016

Action Block

Priority Date
Remarks

DRAFT
NOT FOR
PRODUCTION
12/06/2016
Relocated Sent
Received

Received
Resubmitted

To be completed by an attorney or
BIA-accredited representative (if any).

Select this box if Form G-28 is
attached to represent the
applicant.

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink.

Part 1. Information About You

Provide the following information about yourself.
1.

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

2.

USCIS Online Account Number (if any)
►

3.

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

Your Full Name
4.a. Family Name
(Last Name)
4.b. Given Name
(First Name)

4.c. Middle Name

6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

6.c. Middle Name

Mailing Address

7.a. In Care Of Name (if any)

7.b. Street Number
and Name
7.c.

Apt.

Ste.

Flr.

7.d. City or Town
7.e. State

7.f.

ZIP Code

7.g. Province

Other Names Used

7.h. Postal Code

List all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 11.
Additional Information

7.i.

Country

5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
5.c. Middle Name

Form I-526 06/27/17 N

Page 1 of 13

Part 1. Information About You (continued)

11.a. Street Number
and Name

8.

Is your current mailing address the same as your physical
address?
Yes
No

11.b.

If you answered "No" to Item Number 8., provide your
physical address in Item Numbers 9.a. - 9.h.

11.c. City or Town

Apt.

Ste.

11.d. State

Physical Address

11.g. Postal Code

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9.a. Street Number
and Name
Apt.

11.e. ZIP Code

11.f. Province

Provide your physical addresses for the last five years. Provide
your present address first. If you need extra space to complete
this section, use the space provided in Part 11. Additional
Information.

9.b.

Flr.

11.h. Country

11.i. From (mm/dd/yyyy)

Ste.

Flr.

11.j. To (mm/dd/yyyy)

9.c. City or Town
9.d. State
9.f.

Province

12.a. Street Number
and Name

9.e. ZIP Code

12.b.

Ste.

Flr.

12.c. City or Town

9.g. Postal Code
9.h. Country

Apt.

12.d. State

12.e. ZIP Code

12.f. Province

9.i.

From (mm/dd/yyyy)

9.j.

To (mm/dd/yyyy)

12.g. Postal Code

Present

10.a. Street Number
and Name
10.b.

Apt.

12.h. Country

12.i. From (mm/dd/yyyy)

Ste.

Flr.

12.j. To (mm/dd/yyyy)

10.c. City or Town
10.d. State

10.e. ZIP Code

10.f. Province
10.g. Postal Code
10.h. Country

13.a. Street Number
and Name
13.b.

Apt.

Ste.

Flr.

13.c. City or Town
13.d. State

13.e. ZIP Code

13.f. Province
10.i. From (mm/dd/yyyy)
10.j. To (mm/dd/yyyy)

13.g. Postal Code
13.h. Country

13.i. From (mm/dd/yyyy)
13.j. To (mm/dd/yyyy)
Form I-526 06/27/17 N

Page 2 of 13

Part 1. Information About You (continued)

15.k. From (mm/dd/yyyy)

Employment History

15.l. To (mm/dd/yyyy)

Provide your employment history for the last five years. (If
none, so state.) List present employment first. If you need extra
space to complete this section, use the space provided in Part
11. Additional Information.
14.a. Employer Name

16.a. Employer Name

16.b. Street Number
and Name
16.c.

Apt.

14.g. Province

Ste.

Flr.

14.j. Job Title

16.e. State

16.f. ZIP Code

16.g. Province

14.f. ZIP Code

16.h. Postal Code
16.i. Country

14.h. Postal Code
14.i. Country

Flr.

16.d. City or Town

14.d. City or Town
14.e. State

Ste.

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14.b. Street Number
and Name
14.c.

Apt.

16.j. Job Title

16.k. From (mm/dd/yyyy)
16.l. To (mm/dd/yyyy)

14.k. From (mm/dd/yyyy)

17.a. Employer Name

14.l. To (mm/dd/yyyy)

17.b. Street Number
and Name

15.a. Employer Name

17.c.

15.b. Street Number
and Name
15.c.

Apt.

Ste.

Flr.

17.d. City or Town

Ste.

Flr.

15.d. City or Town
15.e. State

Apt.

17.e. State

17.f. ZIP Code

17.g. Province
15.f. ZIP Code

15.g. Province
15.h. Postal Code

17.h. Postal Code
17.i. Country

17.j. Job Title
15.i. Country

15.j. Job Title

17.k. From (mm/dd/yyyy)
17.l. To (mm/dd/yyyy)

Form I-526 06/27/17 N

Page 3 of 13

Part 1. Information About You (continued)

Your Entry Into the United States

18.a. Employer Name

26.

Date of Arrival (mm/dd/yyyy)

Place of Arrival or Port-of-Entry
18.b. Street Number
and Name
18.c.

Apt.

27.a. City or Town

Ste.

Flr.

18.d. City or Town
18.e. State
18.g. Province

28.a. I-94 Arrival-Departure Record Number
►

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18.f. ZIP Code

28.b. Date Period of Authorized Stay Expires/Expired
(mm/dd/yyyy)

18.h. Postal Code
18.i. Country

27.b. State

28.c. Passport Number

28.d. Travel Document Number

18.j. Job Title

28.e. Country That Issued Passport or Travel Document

28.f. Date Passport or Travel Document Expires (mm/dd/yyyy)

18.k. From (mm/dd/yyyy)
18.l. To (mm/dd/yyyy)

28.g. Current Nonimmigrant Status (if applicable)

Other Information About You
19.

Date of Birth (mm/dd/yyyy)

20.

Sex

Male

28.h. Date Current Nonimmigrant Status Expires (mm/dd/yyyy)

Female

Part 2. Information About Your Investment

Place of Birth
21.

City or Town of Birth

22.

State or Province of Birth

23.

Country of Birth

Regional Center (if any)

1.

Is your investment associated with an approved Regional
Center?
Yes
No

2.

Regional Center Name

3.

Regional Center Identification Number
►

24.

Country of Citizenship or Nationality

NOTE: If you are a citizen of more than one country or your
nationality differs from your citizenship, provide the
information in Part 11. Additional Information.
25.

Country of Last Foreign Residence

Form I-526 06/27/17 N

4.

What is the receipt number for the approved Regional
Center application upon which your petition is based?
►

5.

If applicable, provide the New Commercial Enterprise
(NCE) Identification Number.
►

Page 4 of 13

7.

Part 2. Information About Your Investment
(continued)

This petition is based on an investment in an area for
which the required investment amount of capital has been
adjusted upward.

Petition Type and Required Capital Investment
Select the appropriate box to indicate the type of petition you
are filing. If you select Item Number 6., provide the requested
information.
6.

8.

This petition is based on an investment in a targeted
employment area for which the required investment
amount of capital has been adjusted downward.

Non-TEA/Non-Upward Adjustment Area
This petition is based on an investment in an area that is
neither a targeted employment area nor an upward
adjustment area.

Targeted Employment Area (TEA)

Composition of Your Investment and Your Income

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Composition of Investment

a.

Is the new commercial enterprise (NCE) principally doing
business in a targeted employment area?
Yes
No

b.

Is the area a rural area?

Yes

No

c.

Is the area a high unemployment area?

Yes

No

d.

Address Where the NCE is Principally Doing Business

9.

Flr.

Total Value of Assets Purchased for Use in NCE
$

11.

Total Value of All Property Transferred From Abroad
for Use in NCE
$

12.

Total of All Debt Financing

Street Number
and Name

Ste.

Total Amount Deposited or Committed to Deposit into
U.S. Business Accounts for NCE
$

10.

Apt.

Upward Adjustment Area

$

City or Town
County
State

13.

$

ZIP Code

14.

e.

Is the job-creating-entity (JCE) principally doing business
in a targeted employment area?
Yes
No

f.

Is the area a rural area?

Yes

No

g.

Is the area a high unemployment area?

Yes

No

h.

Address where the JCE is principally doing business

Ste.

Your Gross Income at Time of Investment

16.

Your Net Income at Time of Investment
$

Your Current Gross Income
$

Flr.

18.

Your Current Net Income
$

City or Town
County
State

Form I-526 06/27/17 N

$

$

17.

Street Number
and Name

Other Capital

Your Income
15.

Apt.

Total Stock or Other Equity Purchases

Your Net Worth
ZIP Code

19.

Your Net Worth at Time of Investment
$

20.

Your Current Net Worth
$

Page 5 of 13

Part 2. Information About Your Investment
(continued)
Your Sources of Investment Capital

Address of NCE
3.a. Street Number
and Name

Please identify the sources of the capital you have invested or
are actively in the process of investing into the NCE. (Select all
that apply.)

3.b.

21.a.

Income

3.d. County

21.b.

Indebtedness (Loan, Loan Proceeds, Promissory
Note, etc.)

3.e. State

21.c.

Gift (including capital obtained through inheritance)

4.

Telephone Number of NCE

21.d.

Tangible Assets (Equipment, Inventory, etc.)

21.e.

Other

5.

Type of Entity (for example, corporation, limited liability
company, partnership)

Ste.

Flr.

6.

Nature of Activity (for example, furniture manufacturer)

7.

Included Industries (provide North American Industry
Classification System (NAICS) codes)

8.

Have you invested or are you actively in the process of
investing in a troubled business?
Yes
No

3.c. City or Town

3.f.

ZIP Code

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21.f. In the space below, describe the documentation included
with this petition to demonstrate that the capital you have
invested or are actively in the process of investing was
obtained through lawful means.

Part 3. Information About the New Commercial
Enterprise (NCE)
Type of NCE (Select only one)
1.a.

NCE formed after November 29, 1990

1.b.

NCE resulting from the purchase of a business
formed on or before November 29, 1990 that is
restructured or reorganized

1.c.

NCE resulting from a capital investment in and
substantial expansion of a business formed on or
before November 29, 1990.

NOTE: If you answered "Yes" to Item Number 8., you must
provide an explanation in Part 11. Additional Information of
how the NCE qualifies as a troubled business.
9.

Date NCE Formed (mm/dd/yyyy)

10.

Federal Employer Identification Number
►

11.

Date of Your Initial Investment (mm/dd/yyyy)

12.

Amount of Your Initial Investment in the NCE
$

13.

Your Total Capital Investment in the NCE To Date
$

14.

What percentage of the NCE do you own?

Additional Information About the NCE
2.

Apt.

Name of NCE (Required Field - Do Not Leave Blank)

Form I-526 06/27/17 N

%

Page 6 of 13

Part 3. Information About the New Commercial
Enterprise (NCE) (continued)
Multiple Investors. If you are not the sole investor in the
NCE, list the name of any other person or entity (for example, a
corporation, limited liability company, partnership, etc.) that
holds a percentage ownership of the NCE. Also indicate the
percentage of ownership and whether any of these persons
obtained classification as an alien entrepreneur under INA
section 203(b)(5) on the basis of his or her investment in this
NCE or is seeking classification as an alien entrepreneur under
INA section 203(b)(5). If you need additional space, provide
the information in Part 11. Additional Information.

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. County
3.e. State
4.

3.f.

ZIP Code

Telephone Number of JCE (with area code)

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5.

Type of Entity (for example, corporation, limited liability
company, partnership)

%

6.

Nature of Activity (for example, furniture manufacturer)

15.c. Is the party seeking classification as an alien entrepreneur
under INA Section 203(b)(5) or has the party obtained
classification as an alien entrepreneur under INA section
203(b)(5) on the basis of his or her investment in this NCE?

7.

Included Industries (provide North American Industry
Classification System (NAICS) codes)

15.a. Name of Party

15.b. Percentage of Ownership

Yes

No

16.a. Name of Party

16.b. Percentage of Ownership

%

16.c. Is the party seeking classification as an alien entrepreneur
under INA section 203(b)(5) or has the party obtained
classification as an alien entrepreneur under INA section
203(b)(5) on the basis of his or her investment in this NCE?
Yes

No

Multiple Job-Creating Entities. If there is more than one JCE
involved in the project, provide information regarding all JCE's
involved with the new commercial enterprise. If you need
additional space, use the space provided in Part 11. Additional
Information.
8.

Name of Additional Job-Creating Entity

9.a. Street Number
and Name

9.b.

Apt.

Ste.

Flr.

17.a. Name of Party

9.c. City or Town

17.b. Percentage of Ownership

%

17.c. Is the party seeking classification as an alien entrepreneur
under INA section 203(b)(5) or has the party obtained
classification as an alien entrepreneur under INA section
203(b)(5) on the basis of his or her investment in this NCE?
Yes

No

Part 4. Information About the Job-Creating
Entity (JCE) (if different from the NCE)
1.

Is the JCE different from the NCE?

2.

Name of the JCE

Form I-526 06/27/17 N

Yes

9.d. County

9.e. State

9.f.

ZIP Code

10.

Telephone Number of Job-Creating Entity (with area code)

11.

Type of Entity (for example, corporation, limited liability
company, partnership)

12.

Nature of Activity (for example, furniture manufacturer)

13.

Included Industries (provide North American Industry
Classification System (NAICS) codes)

No

Page 7 of 13

Part 5. Employment Creation Information

Part 6. Processing Information

1.

What is your position, office, or title with the NCE?

Select the appropriate box to indicate how you will seek lawful
permanent resident status.

2.

What are your duties, activities, and responsibilities in the
NCE?

1.a.

NOTE: If you need additional space, provide the information
in Part 11. Additional Information.

Immigrant Visa Processing

1.b. Country of Citizenship or Nationality

1.c. Country of Current Residence

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3.

What is your current salary in the NCE ?
$

4.

What are the costs for benefits you receive in your current
position in the NCE?
$

5.

Number of Full-Time Direct and Qualifying Employees
in the NCE at the Time of Your Initial Investment

2.a.

Application for Adjustment of Status

2.b. Country of Last Permanent Residence Abroad

Address in Country of Last Permanent Residence
Abroad

3.a. Street Number
and Name

6.

Current Number of Full-Time Direct and Qualifying
Employees in the NCE

3.b.

Apt.

Ste.

Flr.

3.c. City or Town

7.

Difference in Number of Full-Time Direct and Qualifying
Employees

3.d. Province

3.e. Postal Code

8.

9.

Estimated Number of Full-Time Direct and Indirect
Positions That Will Be Created During the Relevant Time
Period

If the new commercial enterprise is associated with a
Regional Center, does this petition rely on indirect job
creation?
Yes
No

NOTE: If you answered "Yes" to Item Number 9, indicate the
economic model used to estimate indirect job creation in Part
11. Additional Information.
10.

Total Amount of Your Capital That Has Been or Will Be
Made Available to the JCE

3.f.

Country

4.

Telephone Number

If your native alphabet is other than Roman letters, type or print
the foreign address in your native alphabet, below.
5.a. Street Number
and Name

5.b.

Apt.

Ste.

Flr.

5.c. City or Town

$
11.

Total Amount of Capital Derived From Investors Who
Have Not Sought and Are Not Seeking Classification As
Alien Entrepreneurs
$

Form I-526 06/27/17 N

5.d. Province
5.e. Postal Code
5.f.

Country

Page 8 of 13

Part 6. Processing Information (continued)

Part 7. Information on Petitioner's Spouse and
Children

Immigration Proceedings

List your spouse and all of your children. Also, note if the
individual will be applying for a visa abroad or for adjustment
of status as your dependent. If you need additional space to list
other children, use Part 11. Additional Information.

Please indicate whether you are in exclusion, deportation, or
removal proceedings before the Department of Homeland
Security (DHS) or the Department of Justice's (DOJ), Executive
Office for Immigration Review (EOIR) Immigration Court or
Board of Immigration Appeals. You also must provide an
explanation for why are you in proceedings in Part 11.
Additional Information.
6.

Family Member 1
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

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Are you currently in immigration proceedings before the
Department of Homeland Security (DHS) or Department
of Justice (DOJ)?
Yes
No

1.c. Middle Name

Type of Proceedings (Select only one)

2.

Date of Birth (mm/dd/yyyy)

7.a.

Exclusion

3.

Country of Birth

7.b.

Deportation

7.c.

Removal

4.

Relationship to You

5.

Applying for Adjustment of Status?

Yes

No

6.

Applying for Visa Abroad?

Yes

No

Location of Proceedings
8.a. City or Town

8.b. State

Family Member 2

9.

Are you currently subject to a final order of exclusion,
deportation, or removal, or subject to reinstatement of
such an order?
Yes
No

Employment in the United States
10.
11.

Have you ever worked in the United States without
permission?
Yes

7.a. Family Name
(Last Name)
7.b. Given Name
(First Name)

7.c. Middle Name

No

If you answered "Yes" to Item Number 10., provide an
explanation below. If you need additional space, use
Part 11. Additional Information.

8.

Date of Birth (mm/dd/yyyy)

9.

Country of Birth

10.

Relationship to You

11.

Applying for Adjustment of Status?

Yes

No

12.

Applying for Visa Abroad?

Yes

No

Family Member 3
13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
13.c. Middle Name

Form I-526 06/27/17 N

Page 9 of 13

Part 7. Information on Petitioner's Spouse and
Children (continued)

Family Member 6

14.

Date of Birth (mm/dd/yyyy)

31.a. Family Name
(Last Name)
31.b. Given Name
(First Name)

15.

Country of Birth

31.c. Middle Name

Family Member 3 (continued)

16.

Relationship to You

17.

Applying for Adjustment of Status?

Yes

No

18.

Applying for Visa Abroad?

Yes

No

32.

Date of Birth (mm/dd/yyyy)

33.

Country of Birth

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34.

Relationship to You

35.

Applying for Adjustment of Status?

Yes

No

36.

Applying for Visa Abroad?

Yes

No

Family Member 4
19.a. Family Name
(Last Name)
19.b. Given Name
(First Name)

Part 8. Statement, Contact Information,
Declaration, Certification, and Signature of the
Petitioner or Authorized Signatory

19.c. Middle Name
20.

Date of Birth (mm/dd/yyyy)

21.

Country of Birth

22.

Relationship to You

23.

Applying for Adjustment of Status?

Yes

No

24.

Applying for Visa Abroad?

Yes

No

NOTE: Read the Penalties section of the Form I-526
Instructions before completing this part.

Petitioner's or Authorized Signatory's Statement

NOTE: Select the box for either Item 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
petition and my answer to every question.

1.b.

The interpreter named in Part 9. read to me every
question and instruction on this petition and my
answer to every question in
, a language

Family Member 5
25.a. Family Name
(Last Name)
25.b. Given Name
(First Name)

in which I am fluent. I understood all of this
information as interpreted.
2.

25.c. Middle Name
26.

Date of Birth (mm/dd/yyyy)

27.

Country of Birth

At my request, the preparer named in Part 10.,
prepared this petition for me based only upon
information I provided or authorized.

Authorized Signatory's Contact Information
28.

Relationship to You

29.

Applying for Adjustment of Status?

Yes

No

30.

Applying for Visa Abroad?

Yes

No

Form I-526 06/27/17 N

3.a. Authorized Signatory's Family Name (Last Name)

3.b. Authorized Signatory's Given Name (First Name)

Page 10 of 13

Part 8. Statement, Contact Information,
Declaration, Certification, and Signature of the
Petitioner or Authorized Signatory (continued)
4.

Authorized Signatory's Title

5.

Authorized Signatory's Daytime Telephone Number

6.

Authorized Signatory's Mobile Telephone Number (if any)

7.

Authorized Signatory's Email Address (if any)

Part 9. 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)

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Petitioner's or Authorized Signatory's Declaration
and Certification
Copies of any documents submitted are exact photocopies of
unaltered, original documents, and I understand that, as the
petitioner, I may be required to submit original documents to
USCIS at a later date.

I authorize the release of any information from my records, or
from the petitioning organization's records, to USCIS or other
entities and persons where necessary to determine eligibility for
the immigration benefit sought or where authorized by law. I
recognize the authority of USCIS to conduct audits of this
petition using publicly available open source information. I
also recognize that any supporting evidence submitted in
support of this petition may be verified by USCIS through any
means determined appropriate by USCIS, including but not
limited to, on-site compliance reviews.

If filing this petition on behalf of an organization, I certify that I
am authorized to do so by the organization.
I certify, under penalty of perjury, that I have reviewed this
petition, I understand all of the information contained in, and
submitted with, my petition, and all of this information is
complete, true, and correct.

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.f.

3.e. ZIP Code

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)

Petitioner's or Authorized Signatory's Signature
8.a. Petitioner's Signature

Interpreter's Certification
8.b. Date of Signature (mm/dd/yyyy)

I certify, under penalty of perjury, that:

NOTE TO ALL PETITIONERS AND AUTHORIZED
SIGNATORIES: If you do not completely fill out this petition
or fail to submit required documents listed in the Instructions,
USCIS may delay a decision on or deny your petition.

I am fluent in English and

Form I-526 06/27/17 N

,

which is the same language specified in Part 8., Item 1.b., and I
have read to this petitioner or the authorized signatory in the
identified language every question and instruction on this petition
and his or her answer to every question. The petitioner or
authorized signatory informed me that he or she understands
every instruction, question, and answer on the petition, including
the Petitioner's or Authorized Signatory's Declaration and
Certification, and has verified the accuracy of every answer.
Page 11 of 13

Part 9. Interpreter's Contact Information,
Certification, and Signature (continued)

Preparer's Statement
7.a.

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

7.b.

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

Interpreter's Signature
7.a. Interpreter's Signature

7.b. Date of Signature (mm/dd/yyyy)

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

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Part 10. Contact Information, Declaration, and
Signature of the Person Preparing this Petition,
if Other Than the Petitioner
Provide the following information about the preparer.

Preparer's Certification

Preparer's Full Name

By my signature, I certify, under penalty of perjury, that I
prepared this petition at the request of the petitioner or authorized
signatory. The petitioner has reviewed this completed petition,
including the Petitioner's or Authorized Signatory's
Declaration and Certification, and informed me that all of this
information in the form and in the supporting documents is
complete, true, and correct.

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 Signature

8.a. Preparer's Signature

Preparer's Mailing Address

8.b. Date of Signature (mm/dd/yyyy)

3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

3.c. City or Town
3.d. State
3.f.

Province

3.e. ZIP Code

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)

Form I-526 06/27/17 N

Page 12 of 13

5.a. Page Number

Part 11. Additional Information
If you need extra space to provide any additional information
within this petition, 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 petition 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.

5.b. Part Number

5.c. Item Number

5.d.

1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)

DRAFT
NOT FOR
PRODUCTION
12/06/2016

1.c. Middle Name
2.

A-Number (if any)

3.a. Page Number

3.d.

4.a. Page Number

A-

3.b. Part Number

3.c. Item Number

6.a. Page Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

6.d.

4.b. Part Number

4.d.

Form I-526 06/27/17 N

4.c. Item Number

7.a. Page Number

7.d.

Page 13 of 13