Pages 1-4,
Part 2. Information
About the Beneficiary
|
[Page
1]
Part
2. Information about the Beneficiary
Complete Part 2. regardless
of whether you are filing this form on behalf of yourself as the
beneficiary or on behalf of another individual who is the
beneficiary.
1. Beneficiary’s
Current Legal Name (Do not provide a nickname.)
Family Name (Last Name)
Given Name (First Name)
Middle Name
2. Other Names Used
Provide all other names the
beneficiary has ever used, including aliases, maiden name, and
nicknames. If you need extra space to complete this section, use
the space provided in Part 8. Additional Information.
Family Name (Last Name) [x2]
Given Name (First Name) [x2]
Middle Name [x2]
3. Date of Birth
(mm/dd/yyyy)
4. Gender Male/Female
5. Alien Registration Number
(A-Number)
6. Place of Birth
City or Town
State or Province
Country
7. Country of Citizenship or
Nationality
8. Passport Number of the
beneficiary’s most recently issued passport
Country that issued the most
recently issued passport
Expiration date for the most
recently issued passport
9. Marital Status
Single, Never Married
Married
Divorced
Widowed
Legally Separated
Marriage Annulled
Other (Explain):
[Page 2]
10. Beneficiary’s
Mailing Address
In Care Of Name (if any)
Street Number and Name
Apt./Ste./Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
11. Are the beneficiary’s
mailing address and physical address the same?
Yes/No
If you answered "No" to
Item Number 11., provide the physical address in Item
Number 12.
12. Beneficiary's Physical
Address
In Care Of Name (if any)
Street Number and Name (Do
not provide a PO Box in this space unless it is your ONLY
address.)
Apt./Ste./Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
13. Beneficiary’s
Daytime Telephone Number
14. Beneficiary’s
Mobile Telephone Number
15. Beneficiary’s
Email Address
Beneficiary’s
Anticipated Length of Stay
16.
Beneficiary’s Anticipated Period of Stay in the United
States
From (mm/dd/yyyy)
To (select one):
[] (mm/dd/yyyy)
[] No End
Date
[Page 3]
Beneficiary’s Financial
Information
Provide information about the
beneficiary’s income and assets. If you need additional
space to complete any Item Number in this section, use the
space provided in Part 8. Additional Information.
Beneficiary’s Income
17. Provide all of the
information requested in the table below about the beneficiary,
all of the beneficiary’s dependents, and any other
individuals the beneficiary financially supports (do not include
any individuals named in Part 3.). Information about
assets that are not based on employment should be added in Item
Number 22. and not in Item Number 17.
Table [4 columns, 8 rows] (See Word
Doc for layout)
Individual’s Full Name
(First, Middle, Last) (do not include any individuals named in
Part 3.)
Date of Birth (mm/dd/yyyy)
Relationship to the Beneficiary
(Type or print “Self” if you are filing for
yourself as the beneficiary or “Beneficiary” if
someone is agreeing to support you in Part 3.)
Income contribution to the
beneficiary annually (if none, type or print $0)
Total Number of Dependents
Total Income
18. Does any of the
beneficiary’s total income (including income from dependents
and other individuals who contribute to the beneficiary’s
income, excluding any individuals named in Part 3.) come
from an illegal activity or source (such as proceeds from illegal
gambling or illegal drug sales)?
Yes
No
19. If you answered “Yes”
to Item Number 18., what amount of the beneficiary’s
total income comes from an illegal activity or source? (Type or
print “N/A” if you answered “No” to Item
Number 18.) $_______
20. Does any of the
beneficiary’s total income come from means-tested public
benefits as defined in 8 CFR 213a.1?
Yes
No
21. If you answered “Yes”
to Item Number 20, what amount of the beneficiary’s
total income comes from means-tested public benefits? $______
[Page 4]
Beneficiary’s Assets
22. In the table below,
provide the amounts of assets available to the beneficiary for the
expected period of his or her stay (excluding assets from any
individuals named in Part 3.). Attach evidence showing
that the beneficiary has these assets.
Table [3 columns, 10 rows] (See Word
Doc for layout)
Full Name of Asset Holder
(First, Middle, Last)
Type of Asset
Amount (Cash Value)
(U.S. dollars)
[New]
TOTAL (U.S. dollars) $
|
[Page
1]
[no
change]
5.
Alien Registration Number (A-Number) (if
any)
6. Place of Birth
City or Town
State or Province
Country
7. Country of Citizenship or
Nationality
[deleted]
8.
Marital
Status
Single,
Never Married
Married
Divorced
Widowed
Legally
Separated
Marriage
Annulled
Other
(Explain):
[Page
2]
9.
Beneficiary’s
Mailing Address
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
10.
Are
the beneficiary’s mailing address and physical address the
same?
Yes/No
If
you answered "No" to Item
Number 10.,
provide the physical address in Item
Number 11.
11.
Beneficiary's
Physical Address
In
Care Of Name (if
any)
Street
Number and Name
(Do
not
provide a PO Box in this space unless it is your ONLY
address.)
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[deleted]
Beneficiary’s
Anticipated Length of Stay
12.
Beneficiary’s
Anticipated Period of Stay in the United States
From
(mm/dd/yyyy)
To
(select one):
[]
(mm/dd/yyyy)
[]
No End Date
[Page
3]
Beneficiary’s
Financial Information
Provide information about the
beneficiary’s income and assets. If you need additional
space to complete any Item Number in this section, use the
space provided in Part 8. Additional Information.
Beneficiary’s Income
13.
Provide all of the information requested in the table
below about the beneficiary, all of the beneficiary’s
dependents, and any other individuals the beneficiary financially
supports (do not include any individuals named in Part 3.).
Information about assets that are not based on employment should
be added in Item Number 16. and
not in Item Number 13.
Table [4 columns, 8 rows] (See Word
Doc for layout)
Individual’s Full Name
(First, Middle, Last) (do not include any individuals named in
Part 3.)
Date of Birth (mm/dd/yyyy)
Relationship to the Beneficiary
(Type or print “Self” if you are filing for
yourself as the beneficiary or “Beneficiary” if
someone is agreeing to support you in Part 3.)
Income contribution to the
beneficiary annually (if none, type or print $0)
Total Number of Dependents
Total Income
14.
Does any of the beneficiary’s total income (including
income from dependents and other individuals who contribute to the
beneficiary’s income, excluding any individuals named in
Part 3.) come from an illegal activity or source (such as
proceeds from illegal gambling or illegal drug sales)?
Yes
No
15.
If you answered “Yes” to Item Number 14.,
what amount of the beneficiary’s total income comes from an
illegal activity or source? $_______
[deleted]
[deleted]
[Page 4]
Beneficiary’s Assets
16.
In the table below, provide the amounts of assets
available to the beneficiary for the expected period of his or her
stay (excluding assets from any individuals named in Part 3.).
Attach evidence showing that the beneficiary has these assets.
Table [3 columns, 10 rows] (See Word
Doc for layout)
Full Name of Asset Holder
(First, Middle, Last)
Type of Asset
Amount (Cash Value)
(U.S. dollars)
Current Cash
Value (U.S. dollars) $
TOTAL (U.S. dollars) $
|
Pages 4-8,
Part 3. Information
About the Individual Agreeing to Financially Support the
Beneficiary Named in Part 2.
|
[Page 4]
Part
3. Information About the Individual Agreeing to Financially
Support the Beneficiary Named in Part 2.
If you are not the beneficiary named
in Part 2., complete Part 3.
1. Current Legal Name (Do
not provide a nickname.)
Family Name (Last Name)
Given Name (First Name)
Middle Name
2. Other Names Used
Provide 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 8. Additional Information.
Family Name (Last Name) [x2]
Given Name (First Name) [x2]
Middle Name [x2]
3. Current Mailing Address
In Care Of Name (if any)
Street Number and Name
Apt./Ste./Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
[Page 5]
4. Is your current mailing
address the same as your current physical address?
Yes/No
If you answered "No" to
Item Number 4., provide your current physical address in
Item Number 5.
5. Physical Address
In Care Of Name (if any)
Street Number and Name
Apt./Ste./Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Other Information
6. Date of Birth
(mm/dd/yyyy)
7. Place of Birth
City or Town
State or Province
Country
8. Alien Registration
Number (A-Number)
9. USCIS Online Account
Number
10. What is your relationship
to the beneficiary?
Immigration Status
11. What is your current
immigration status? Provide documentation as provided in the
instructions.
U.S. Citizen
U.S. National
Lawful Permanent Resident
Nonimmigrant Form I-94
Arrival/Departure Record Number
Other (Explain): ______
[Page 6]
Employment Information
12. Employment Status
[ ] Employed (full-time, part-time,
seasonal, self-employed)
[ ] Unemployed or Not Employed
[ ] Retired
[ ] Other (Explain):
If you indicated that you are
employed in Item Number 12., provide the information
requested in Item Numbers 13. - 14.
13.A. I am currently employed
as a/an
Name of Employer
B. I am currently
self-employed as a/an
14. Current Employer’s
Address
Street Number and Name
Apt./Ste./Flr.
Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Financial Information
Provide information about your
income and assets. If you need additional space to complete any
Item Number in this section, use the space provided in Part
8. Additional Information.
Income
15.
Provide all of the information requested in the table below about
yourself, all of your dependents, and any other individuals you
financially support (do not include any individuals named in Part
2.). Information about assets that are not based on
employment should be added in Item Number 20. and not in
Item Number 15.
Table [4 columns, 8 rows] (See Word
Doc for layout)
Full Name (First, Middle,
Last) (do not include any individuals named in Part 2.)
Date of Birth (mm/dd/yyyy)
Relationship to the Individual
Agreeing to Financially Support (Type or print “Self”
for Individual Agreeing to Financially Support the Beneficiary)
Income Contribution to the
Beneficiary Annually (if none, type or print $0)
Total Number of Dependents
Total Income
[Page 7]
16. Does any of the income
listed above come from an illegal activity or source (such as
proceeds from illegal gambling or illegal drug sales)?
Yes
No
17. If you answered “Yes”
to Item Number 16., what amount of income comes from an
illegal activity? $______
18. Does any of the income
listed above come from means-tested public benefits as defined in
8 CFR 213a.1?
Yes
No
19. If you answered “Yes”
to Item Number 18., what amount of income is from
means-tested public benefits $______
Assets
20. Fill out the table below
regarding the assets available to you (do not include any
assets from any individuals named in Part 2.). Attach
evidence showing you have these assets.
Table [3 columns, 10 rows] (See Word
Doc for layout)
Full Name of Asset Holder
(you or your household member)
Type of Asset
Amount (Cash Value)
(U.S. dollars)
[New]
TOTAL (U.S. dollars) $
Financial Responsibility for
Other Beneficiaries
21. Have you previously
submitted a Form I-134 on behalf of a person other than the
beneficiary named in Part 2?
Yes
No
If you answered “Yes” to
Item Number 21., provide the information requested in Item
Numbers 22. - 23. If you need additional space to complete
this section, use the space provided in Part 8. Additional
Information.
22. Person 1
Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number
Date Submitted (mm/dd/yyyy)
23. Person 2
Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number
Date Submitted (mm/dd/yyyy)
[Page 8]
Intent to Provide Specific
Contributions to the Beneficiary
24. I [] intend [] do not
intend to make specific contributions to the support of the
beneficiary named in Part 2.
Explain the contribution. For
example, if you intend to furnish room and board, state for how
long. If you intend to provide money, state the amount in U.S.
dollars and whether it is to be given in a lump sum, weekly, or
monthly, and for how long. If you need additional space, use Part
8. Additional Information.
|
[Page 4]
Part
3. Information About the Individual Agreeing to Financially
Support the Beneficiary Named in Part 2.
If
you are not the beneficiary named in Part
2.,
complete Part
3.
1.
Current
Legal Name
(Do
not provide
a nickname.)
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
2.
Other
Names Used
Provide
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
8. Additional Information.
Family
Name (Last Name) [x2]
Given
Name (First Name) [x2]
Middle
Name [x2]
3.
Current
Mailing Address
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
[Page
5]
4.
Is your current mailing address the same as your current physical
address?
Yes/No
If
you answered "No" to Item
Number 4.,
provide your current physical address in Item
Number 5.
5.
Physical
Address
In
Care Of Name (if any)
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Other
Information
6.
Date
of Birth (mm/dd/yyyy)
7.
Place
of Birth
City
or Town
State
or Province
Country
8.
Alien
Registration Number (A-Number) (if
any)
9.
USCIS Online Account Number (if
any)
[deleted]
Immigration
Status
10.
What
is your current immigration status? Provide documentation as
provided in the instructions.
U.S.
Citizen
U.S.
National
Lawful
Permanent Resident A-Number
Nonimmigrant
Form I-94 Arrival/Departure Record Number
Other
(Explain): ______
[Page
6]
Employment
Information
11.
Employment Status
[ ] Employed (full-time, part-time,
seasonal, self-employed)
[ ] Unemployed or Not Employed
[ ] Retired
[ ] Other (Explain):
If
you indicated that you are employed in Item
Number 11.,
provide the information requested in Item
Numbers 12.
- 13.
12.A.
I
am currently employed as a/an
Name
of Employer
B.
I am currently self-employed as a/an
13.
Current
Employer’s Address
Street
Number and Name
Apt./Ste./Flr.
Number
City
or Town
State
ZIP
Code
Province
Postal
Code
Country
Financial
Information
Provide
information about your income and assets. If you need additional
space to complete any Item
Number
in this section, use the space provided in Part
8. Additional Information.
Income
14.
Provide all of the information requested in the table below
about yourself, all of your dependents, and any other individuals
you financially support (do not include any individuals named in
Part 2.). Information about assets that are not based on
employment should be added in Item Number 17.
and not in Item Number 14.
Table [4 columns, 8 rows] (See Word
Doc for layout)
Full Name (First, Middle,
Last) (do not include any individuals named in Part 2.)
Date of Birth (mm/dd/yyyy)
Relationship to the Individual
Agreeing to Financially Support (Type or print “Self”
for Individual Agreeing to Financially Support the Beneficiary)
Income Contribution to the
Beneficiary Annually (if none, type or print $0)
Total Number of Dependents
Total Income
[Page 7]
15.
Does any of the income listed above come from an illegal
activity or source (such as proceeds from illegal gambling or
illegal drug sales)?
Yes
No
16.
If you answered “Yes” to Item Number 15.,
what amount of income comes from an illegal activity? $______
[deleted]
[deleted]
Assets
17.
Fill out the table below regarding the assets available to you
(do
not include any assets from any individuals named in Part
2.).
Attach evidence showing you have these assets.
Table [3 columns, 10 rows] (See Word
Doc for layout)
Full Name of Asset Holder
(you or your household member)
Type of Asset
Amount (Cash Value)
(U.S. dollars)
Current Cash
Value (U.S. dollars) $
TOTAL (U.S. dollars) $
Financial
Responsibility for Other Beneficiaries
18.
Have
you previously submitted a Form I-134 on behalf of a person other
than the beneficiary listed
on this Form I-134?
Yes
No
If
you answered “Yes” to Item
Number 20.,
provide the information requested in Item
Numbers 19.
- 20.
If you need additional space to complete this section, use the
space provided in Part
8. Additional Information.
19.
Person
1
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
A-Number
Date
Submitted (mm/dd/yyyy)
20.
Person
2
Family
Name (Last Name)
Given
Name (First Name)
Middle
Name
A-Number
Date
Submitted (mm/dd/yyyy)
[Page 8]
Intent
to Provide Specific Contributions to the Beneficiary
21.
I
[] intend [] do not intend to make specific contributions to the
support of the beneficiary named in Part
2.
Explain
the contribution. For example, if you intend to furnish room and
board, state for how long. If you intend to provide money, state
the amount in U.S. dollars and whether it is to be given in a lump
sum, weekly, or monthly, and for how long. If you need additional
space, use Part
8. Additional Information.
|
Pages 8-9
Part
4. Statement, Contact Information, Certification, and Signature
of the Beneficiary (Only complete this section if Part 1. Basis
for Filing selection is “Myself as the beneficiary”,
otherwise continue to Part 5.)
|
[Page 8]
Part 4. Statement, Contact
Information, Certification, and Signature of the Beneficiary (Only
complete this section if Part 1. Basis for Filing selection is
“Myself as the beneficiary”, otherwise continue to
Part 5.)
If you are the beneficiary and are
filing Form I-134 on your own behalf, complete and sign Part 4.
NOTE: Read the Penalties
section of the Form I-134 Instructions before completing this
section.
Beneficiary’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. I, as the beneficiary,
certify the following:
A. I can read and understand
English, and I have read and understand every question and
instruction on this declaration and my answer to every question.
B. The interpreter named in
Part 6. read to me every question and instruction on this
declaration 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 Field], prepared this
declaration for me based only upon information I provided or
authorized.
[New]
Beneficiary’s
Certification
Copies of any documents I have
submitted are exact photocopies of unaltered, original documents,
and I understand that USCIS or the Department of State may require
that I submit original documents to USCIS or the Department of
State at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS or the
Department of State may need to determine my eligibility for the
immigration benefit I seek.
I further authorize release of
information contained in this declaration, in supporting
documents, and in my USCIS or the Department of State records, to
other entities and persons where necessary for the administration
and enforcement of U.S. immigration law.
[Page 9]
I understand that USCIS may require
me to appear for an appointment to take my biometrics
(fingerprints, photograph, and/or signature) and, at that time, if
I am required to provide biometrics, I will be required to sign an
oath reaffirming that:
1) I reviewed and provided or
authorized all of the information in my declaration;
2) I understood all of the
information contained in, and submitted with, my declaration; and
3) All of this information
was complete, true, and correct at the time of filing.
I certify, under penalty of perjury,
that I provided or authorized all of the information in my
declaration, I understand all of the information contained in, and
submitted with, my declaration, and that all of this information
is complete, true, and correct.
That this declaration is made by me
to assure the U.S. Government that I will be able to financially
support myself while in the United States.
That I am willing and able to pay
for necessary expenses for the duration of my temporary stay in
the United States.
Beneficiary’s Signature
3. Beneficiary’s
Signature
Date of Signature (mm/dd/yyyy)
|
[Page 8]
Part
4. Statement, Contact Information, Certification, and Signature
of the Beneficiary (if
filing Form I-134 on his or her own behalf)
If
you are the beneficiary and are filing Form I-134 on your own
behalf, complete and sign Part
4.
NOTE:
Read the Penalties
section of the Form I-134 Instructions before completing this
section.
Beneficiary’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.
I,
as the beneficiary, certify the following:
A.
I can read and understand English, and I have read and understand
every question and instruction on this declaration and my answer
to every question.
B.
The interpreter named in Part
6.
read to me every question and instruction on this declaration 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 Field], prepared this declaration for me based only upon
information I provided or authorized.
Beneficiary's
Contact Information
3.
Beneficiary’s Daytime Telephone Number
4.
Beneficiary’s Mobile Telephone Number (if any)
5.
Beneficiary’s Email Address (if any)
Beneficiary’s
Certification
[no
change]
|
Pages 9-10, Part 5.
Statement, Contact Information, Certification, and Signature of
the Individual Agreeing to Financially Support the Beneficiary
|
[Page 9]
Part 5. Statement, Contact
Information, Certification, and Signature of the Individual
Agreeing to Financially Support the Beneficiary
If you are filing Form I-134 on
behalf of someone else (the beneficiary listed in Part 2.),
complete and sign Part 5.
NOTE: Read the Penalties
section of the Form I-134 Instructions before completing this
section.
Statement of Individual
Agreeing to Financially Support the Beneficiary
NOTE: Select the box for
either Item A. or B. in Item Number 1. If
applicable, select the box for Item Number 2.
1. I, as the individual
agreeing to financially support the beneficiary, certify the
following:
A. I can read and understand
English, and I have read and understand every question and
instruction on this declaration and my answer to every question.
B. The interpreter named in
Part 6. read to me every question and instruction on this
declaration 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 Field], prepared this
declaration for me based only upon information I provided or
authorized.
Contact Information for
Individual Agreeing to Financially Support the Beneficiary
3. Daytime Telephone Number
4. Mobile Telephone Number
(if any)
5. Email Address (if any)
[Page 10]
Certification of Individual
Agreeing to Financially Support the Beneficiary
Copies of any documents I have
submitted are exact photocopies of unaltered, original documents,
and I understand that USCIS or the Department of State may require
that I submit original documents to USCIS or the Department of
State at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS or the
Department of State may need to determine my eligibility for the
immigration benefit I seek.
I further authorize release of
information contained in this declaration, in supporting
documents, and in my USCIS or the Department of State records, to
other entities and persons where necessary for the administration
and enforcement of U.S. immigration law.
I understand that USCIS may require
me to appear for an appointment to take my biometrics
(fingerprints, photograph, and/or signature) and, at that time, if
I am required to provide biometrics, I will be required to sign an
oath reaffirming that:
1) I reviewed and provided or
authorized all of the information in my declaration;
2) I understood all of the
information contained in, and submitted with, my declaration; and
3) All of this information
was complete, true, and correct at the time of filing.
I certify, under penalty of perjury,
that I provided or authorized all of the information in my
declaration, I understand all of the information contained in, and
submitted with, my declaration, and that all of this information
is complete, true, and correct.
That this declaration is made by me
to assure the U.S. Government that the person named in Part 2.
will be financially supported while in the United States.
That I am willing and able to
receive, maintain, and support the person named in Part 2. to
better ensure that such persons will have sufficient financial
resources or financial support to pay for necessary expenses for
the period of his or her temporary stay in the United States.
I acknowledge that I have read this
section, and I am aware of my responsibilities as an individual
agreeing to financially support the beneficiary.
Signature of Individual
Agreeing to Financially Support the Beneficiary
6. Signature
Date of Signature (mm/dd/yyyy)
NOTE TO ALL INDIVIDUALS AGREEING
TO FINANCIALLY SUPPORT THE BENEFICIARY: If you do not
completely fill out this declaration or if you fail to submit
required documents listed in the Instructions, USCIS or the
Department of State may deny or not consider your declaration.
|
[Page
9]
Part
5. Statement, Contact Information, Certification, and Signature
of the Individual Agreeing to Financially Support the Beneficiary
[no
change]
|
Pages 10-11, Part 6.
Interpreter's Contact Information, Certification, and Signature
|
[Page
10]
Part 6. 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
[Fillable Field], which is the same language specified
in Part 4. or in Part 5., Item B. in Item
Number 1., and I have read to this individual agreeing to
financially support the beneficiary in the identified language
every question and instruction on this declaration and his or her
answer to every question. The individual agreeing to financially
support the beneficiary informed me that he or she understands
every instruction, question, and answer on the declaration,
including the Certification of the Individual Agreeing to
Financially Support the Beneficiary, and has verified the
accuracy of every answer.
Interpreter's Signature
7. Interpreter's
Signature
Date of Signature (mm/dd/yyyy)
|
[Page
10]
Part
6. Interpreter's Contact Information, Certification, and
Signature
[no
change]
|
Pages 11-12, Part 7.
Contact Information, Declaration, and Signature of the Person
Preparing this Declaration, if Other Than the Individual Agreeing
to Financially Support the Beneficiary
|
[Page
11]
Part 7. Contact
Information, Declaration, and Signature of the Person Preparing
this Declaration, if Other Than the Individual Agreeing to
Financially Support the Beneficiary
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
6. Preparer's Email
Address (if any)
[Page 12]
Preparer's Statement
7.A. I am not an
attorney or accredited representative but have prepared this
declaration on behalf of the individual agreeing to financially
support the beneficiary (which is the beneficiary if filing on
behalf of him or herself) and with that individual’s
consent.
B. I am an attorney or
accredited representative and my representation of the individual
agreeing to financially support the beneficiary (which is the
beneficiary if filing on behalf of him or herself) in this case
extends/does not extend beyond the preparation of this
declaration.
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 application.
Preparer's Certification
By my signature, I certify, under
penalty of perjury, that I prepared this declaration at the
request of the individual agreeing to financially support the
beneficiary (which is the beneficiary if filing on behalf of him
or herself). The individual agreeing to financially support the
beneficiary (which is the beneficiary if filing on behalf of him
or herself) then reviewed this completed declaration and informed
me that he or she understands all of the information contained in,
and submitted with, his or her declaration, including the
Certification of the Individual Agreeing to Financially Support
the Beneficiary, and that all of this information is complete,
true, and correct. I completed this declaration based only on
information that the individual agreeing to financially support
the beneficiary provided to me or authorized me to obtain or use.
Preparer's Signature
8. Preparer's
Signature
Date of
Signature (mm/dd/yyyy)
|
[Page
11]
[no
change]
|