Fillable Form-I-130a Form I-130A

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Form-I-130a Form I-130A

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Form I-130A 02/27/17 N Page 1 of 6
USCIS
Form I-130A
OMB No. 1615-0012
Expires 07/31/2018
To be completed by an attorney or accredited representative (if any).
START HERE - Type or print in black ink.►
Part 1. Information About You (Spouse
Beneficiary)
4.c.
4.f.
4.h.
4.g.
4.d.
4.a.
4.b.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 4.e. ZIP Code
Province
Country
Postal Code
Physical Address 1
Address History
Provide your physical addresses for the last five years, whether
inside or outside the United States. Provide your current
address first. If you need extra space to complete this section,
use the space provided in Part 7. Additional Information.
6.c.
6.f.
6.h.
6.g.
6.d.
6.a.
6.b.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 6.e. ZIP Code
Province
Country
Postal Code
Physical Address 2
Select this box if
Form G-28 is
attached.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
Date From (mm/dd/yyyy)7.a.
Date To (mm/dd/yyyy)7.b.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Your Full Name
3.c.
3.b.
3.a.
1. Alien Registration Number (A-Number) (if any)
►
►
A-
USCIS Online Account Number (if any)2.
Date From (mm/dd/yyyy)5.a.
Date To (mm/dd/yyyy)5.b.
Postal Code
Country
Province
City or Town
Apt. Ste. Flr.
Street Number
and Name
8.b.
8.a.
8.e.
8.f.
8.d.
8.c.
Provide your last address outside the United States of more than
one year (even if listed above).
The purpose of this form is to collect additional information for a spouse beneficiary of Form I-130, Petition for Alien Relative. If
your spouse is a U.S. citizen, lawful permanent resident, or non-citizen U.S. national who is filing Form I-130 on your behalf, you
must complete and sign Form I-130A, Supplemental Information for Spouse Beneficiary, and submit it with the Form I-130 filed by
your spouse. If you reside overseas, you still must complete Form I-130A, but you do not need to sign the form.
Volag Number
(if any)
Last Physical Address Outside the United States
Supplemental Information for Spouse Beneficiary
Department of Homeland Security
U.S. Citizenship and Immigration Services
35 Chamberlain Street
Sydney
NSW
Australia
12345
SMITH
Jane
Joan
08/12/2009
PRESENT
12345
Australia
NSW
Sydney
35 Chamberlain Street
Form I-130A 02/27/17 N Page 2 of 6
9.b. Date To (mm/dd/yyyy)
9.a. Date From (mm/dd/yyyy)
Part 1. Information About You (The Spouse
Beneficiary)
Full Name of Parent 1
Information About Parent 1
Given Name
(First Name)
Middle Name
13. City/Town/Village
of Birth
14.
16. Country of Residence
City/Town/Village of Residence15.
Country of Birth
11. Date of Birth (mm/dd/yyyy)
Family Name
(Maiden Name)
Part 2. Information About Your Employment
Provide your employment history for the last five years,
whether inside or outside the United States. Provide your
current employment first. If you are currently unemployed,
type or print "Unemployed" in Item Number 1. below. If you
need extra space to complete this section, use the space
provided in Part 7. Additional Information.
Employment History
City or Town2.c.
2.f.
2.h.
Province
Country
2.g. Postal Code
ZIP Code2.e.State2.d.
Street Number
and Name
2.a.
2.b. Apt. Ste. Flr.
Employer 1
1. Name of Employer/Company
Date of Birth (mm/dd/yyyy)18.
Country of Birth
22. City/Town/Village of Residence
Country of Residence23.
21.
City/Town/Village
of Birth
20.
Middle Name
Given Name
(First Name)
Information About Parent 2
17.a.
Full Name of Parent 2
Family Name
(Last Name)
3. Your Occupation
Date From (mm/dd/yyyy)4.a.
Date To (mm/dd/yyyy)4.b.
City or Town6.c.
6.f.
6.h.
Province
Country
6.g. Postal Code
ZIP Code6.e.State6.d.
Street Number
and Name
6.a.
6.b. Apt. Ste. Flr.
Employer 2
5. Name of Employer/Company
10.a.
10.b.
10.c.
17.b.
17.c.
12. Sex
Male Female
19. Sex
Male Female
09/17/2017
08/12/2009
Jack
Jones
Sydney
Sydney
Australia
Australia
07/07/1945
DOALLY
555 West Way Drive
Sydney
NSW
12345
Australia
Beta Computing
09/20/1951
Australia
Australia
Sydney
Jones
Emily
DOALLY
Accountant
08/12/2009
PRESENT
Form I-130A 02/27/17 N Page 3 of 6
Part 2. Information About Your Employment
(continued)
7. Your Occupation
3.
Provide your last occupation outside the United States if not
shown above. If you never worked outside the United States,
provide this information in the space provided in Part 7.
Additional Information.
Your Occupation
1. Name of Employer/Company
Date From (mm/dd/yyyy)8.a.
Date To (mm/dd/yyyy)8.b.
Date From (mm/dd/yyyy)4.a.
Date To (mm/dd/yyyy)4.b.
Part 3. Information About Your Employment
Outside the United States
The interpreter named in Part 5. read to me every
question and instruction on this form and my answer
to every question in
1.b.
a language in which I am fluent, and I understood
everything.
,
2. At my request, the preparer name in Part 6.,
prepared this form for me based only upon
information I provided or authorized.
,
Spouse Beneficiary's Daytime Telephone Number3.
Spouse Beneficiary's Contact Information
Spouse Beneficiary's Email Address (if any)5.
Spouse Beneficiary's Mobile Telephone Number (if any)4.
Spouse Beneficiary'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 form,
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.
City or Town2.c.
2.f.
2.h.
Province
Country
2.g. Postal Code
ZIP Code2.e.State2.d.
Street Number
and Name
2.a.
2.b. Apt. Ste. Flr.
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.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
Part 4. Spouse Beneficiary's Statement, Contact
Information, Certification, and Signature
Spouse Beneficiary's Statement
NOTE: Read the Penalties section of the Form I-130 and
Form I-130A Instructions before completing this part.
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, my form, and that
all of this information is complete, true, and correct.
Spouse Beneficiary's Signature
Date of Signature (mm/dd/yyyy)6.b.
Spouse Beneficiary's Signature (sign in ink)6.a.
NOTE TO ALL SPOUSE BENEFICIARIES: If you do not
completely fill out this form or fail to submit required documents
listed in the Instructions, USCIS may deny the Form I-130 filed
on your behalf.
2223334444
email@gmail.com
2223334444
09/17/2017
Don't forget to sign in ink!
Form I-130A 02/27/17 N Page 4 of 6
Interpreter's Business or Organization Name (if any)2.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Part 5. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter you used
to complete Form I-130A if he or she is different from the
interpreter used to complete the Form I-130 filed on your behalf.
Interpreter's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code
Street Number
and Name
3.a.
3.b. Apt. Ste. Flr.
3.g.
3.h. Country
Province
Interpreter's Certification
I am fluent in English and
which is the same language provided in Part 4., Item Number
1.b., and I have read to this spouse beneficiary in the identified
language every question and instruction on this form and his or
her answer to every question. The spouse beneficiary informed
me that he or she understands every instruction, question, and
answer on the form, including the Spouse Beneficiary's
Certification, and has verified the accuracy of every answer.
I certify, under penalty of perjury, that:
,
Interpreter's Signature
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature (sign in ink)7.a.
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Spouse Beneficiary
Provide the following information about the preparer you used
to complete Form I-130A if he or she is different from the
preparer used to complete the Form I-130 filed on your behalf.
Preparer's Given Name (First Name)1.b.
2. Preparer's Business or Organization Name (if any)
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Interpreter's Contact Information
Interpreter's Daytime Telephone Number4.
Interpreter's Email Address (if any)6.
Interpreter's Mobile Telephone Number (if any)5.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
Postal Code
Street Number
and Name
3.a.
3.b. Apt. Ste. Flr.
3.g.
3.h. Country
Province
Form I-130A 02/27/17 N Page 5 of 6
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this Form, if
Other Than the Spouse Beneficiary (continued)
Preparer's Contact Information
Preparer's Mobile Telephone Number (if any)5.
Preparer's Daytime Telephone Number4.
Preparer's Email Address (if any)6.
Preparer's Statement
I am not an attorney or accredited representative but
have prepared this form on behalf of the spouse
beneficiary and with the spouse beneficiary's consent.
7.a.
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.
I am an attorney or accredited representative and my
representation of the spouse beneficiary in this case
extends does not extend beyond the preparation
7.b.
of this form.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
prepared this form at the request of the spouse beneficiary. The
spouse beneficiary 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
Spouse Beneficiary's Certification, and that all of this
information is complete, true, and correct. I completed this
form based only on information that the spouse beneficiary
provided to me or authorized me to obtain or use.
Preparer's Signature
8.a. Preparer's Signature (sign in ink)
8.b. Date of Signature (mm/dd/yyyy)
Form I-130A 02/27/17 N Page 6 of 6
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.
A-Number (if any) ►
A-
3.a.
2.
Page Number 3.b. Part Number 3.c. Item Number
3.d.
Page Number
Part Number Item Number
Page Number Part Number Item Number5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
5.d.
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
4.c.4.b.
4.d.
4.a.
6.d.
6.c.6.b.6.a.
Page Number Part Number Item Number
7.d.
7.c.7.b.7.a.
SMITH
Jane
Joan
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Form-I-130a Form I-130A

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Completed 3 July 2020

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