Form I-363 03/01/17 N Page 5 of 7
I am not an attorney or accredited representative
but have prepared this application on behalf of
the applicant and with the applicant's consent.
I am an attorney or accredited representative and
my representation of the applicant in this case
preparation of this application.
does not extend beyond the
NOTE: If you are an attorney or accredited
representative whose representation extends
beyond preparation of this application, you may
be obliged to submit a completed Form G-28,
Notice of Entry of Appearance as Attorney or
Accredited Representative, with this request.
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 request and informed
me that he or she understands all of the information contained
in, and submitted with, his or her request, including the
Applicant's Certification, and that all of this information is
complete, true, and correct. I completed this request based only
on information that the applicant provided to me or authorized
me to obtain or use.
Preparer's Signature (sign in ink)
8.b. Date of Signature (mm/dd/yyyy)
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Given Name (First Name)1.b.
2. Preparer's Business or Organization Name
Preparer's Full Name
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
Preparer's Mailing Address
3.c. City or Town
Preparer's Contact Information
Preparer's Mobile Telephone Number (if any)5.
Preparer's Daytime Telephone Number4.
Preparer's Email Address (if any)6.
Part 5. Interpreter's Contact Information,
Certification, and Signature (continued)
I am fluent in English and
which is the same language specified in Part 4., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this request and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
request, including the Applicant's Certification, and has
verified the accuracy of every answer.
I certify, under penalty of perjury, that:
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature (sign in ink)