Last Name (Family Name)
Middle Initial
First Name (Given Name)
Employee Name:
ZIP Code
Address (Street Number and Name)
First Name (Given Name)
Last Name (Family Name)
Date (mm/dd/yyyy)
Signature of Preparer or Translator
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
City or Town
Instructions: This supplement may be used if extra spaces are required to document more than one preparer and/or translator
assisting an employee in completing Section 1 of Form I-9. The preparer and/or translator must enter the employee's name in
the spaces provided. Each preparer or translator must complete, sign and date a separate certification area. Employers must
retain completed supplement sheets with the employee's completed Form I-9.
State
ZIP Code
Address (Street Number and Name)
First Name (Given Name)
Last Name (Family Name)
Date (mm/dd/yyyy)
Signature of Preparer or Translator
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
City or Town State
ZIP Code
Address (Street Number and Name)
First Name (Given Name)
Last Name (Family Name)
Date (mm/dd/yyyy)
Signature of Preparer or Translator
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
City or Town State
ZIP Code
Address (Street Number and Name)
First Name (Given Name)
Last Name (Family Name)
Date (mm/dd/yyyy)
Signature of Preparer or Translator
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
City or Town State
USCIS
Form I-9
Supplement
OMB No. 1615-0047
Expires 10/31/2022
Form I-9 Supplement,
Section 1 Preparer and/or Translator Certification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 Supplement 10/21/2019 Page 1 of 1
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