Fillable I-865 Application for Civil Surgeon Designation

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I-865 Application for Civil Surgeon Designation

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The I-865 Application for Civil Surgeon Designation form is 5 pages long and contains:

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Country of origin: US
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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Page 1 of 5Form I-865 07/17/15 N
For
USCIS
Use
Only
Sponsor's Notice of Change of Address
Department of Homeland Security
U.S. Citizenship and Immigration Services
START HERE - Type or print in black ink.►
USCIS
Form I-865
Action Block
Resubmitted
Remarks
Part 1.
Information About You (Sponsor)
CSID Number:
Date
Date
Returned
Date
Date
Your New Physical Address
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Your Full Name
City or Town3.c.
Street Number
and Name
3.a.
3.b. Apt.
Flr.
Ste.
3.f.
3.h.
Province
Country
3.g.
Postal Code
ZIP Code
3.e.
State
3.d.
Other Information
2. Date of Birth (mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy) (mm/dd/yyyy)
(mm/dd/yyyy)
Effective Date of Change of Address (mm/dd/yyyy)4.
City or Town6.d.
Street Number
and Name
6.b.
6.c. Apt.
Flr.Ste.
6.g.
6.i.
Province
Country
6.h.
Postal Code
ZIP Code
6.f.
State
6.e.
Effective Date of Change of Address (mm/dd/yyyy)7.
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Part 2. Information About the Sponsored
Immigrants
Provide the requested information on the persons you are
sponsoring.
In Care Of Name (if any)6.a.
Your New Mailing Address
Is your new physical address the same as your new
mailing address?
5.
NoYes
If you answered "No" to Item Number 5., provide your
new mailing address in Item Numbers 6.a. - 7.
Sponsored Immigrant 1
Alien Registration Number (A-Number) (if any)2.
A-
►
Page 2 of 5Form I-865 07/17/15 N
Part 2. Information About the Sponsored
Immigrants (continued)
NOTE: If you are sponsoring more than four persons, use the
space provided in Part 6. Additional Information to provide
the information requested for each additional individual.
Sponsored Immigrant 2
3.b.
3.c.
3.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
A-Number (if any)4.
A-
►
Sponsored Immigrant 3
5.b.
5.c.
5.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
A-Number (if any)6.
A-
►
Sponsored Immigrant 4
7.b.
7.c.
7.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
A-Number (if any)8.
A-
►
1.b.
The interpreter named in Part 4. has also read to me
every question and instruction on this notice, as well
as my answer to every question, in
a language in which I am fluent. I understand every
question and instruction on this notice as translated to
me by my interpreter, and have provided complete,
true, and correct responses in the language indicated
above.
,
I have requested the services of and consented to
2.
is is not an attorney or a accredited
representative, preparing this notice for me.
,
who
Sponsor's Contact Information
Sponsor's Daytime Telephone Number
3.
4.
5.
Sponsor's Mobile Telephone Number (if any)
Sponsor's Email Address (if any)
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 and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.
Sponsor's Certification
Part 3. Sponsor's Statement, Contact
Information, Certification, and Signature
NOTE: Read the information on penalties in the Penalties
section of the Form I-865 Instructions before completing this
part.
I can read and understand English, and have read and
understand every question and instruction on this
notice, as well as my answer to every question.
1.a.
Sponsor's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
I furthermore authorize release of information contained in this
notice, 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.
I certify, under penalty of perjury, that the information in my
notice and any document submitted with my notice were
provided by me and are complete, true, and correct.
Sponsor's Signature
Date of Signature (mm/dd/yyyy)6.b.
Sponsor's Signature6.a.
NOTE TO ALL SPONSORS: If you do not completely fill
out this notice or fail to submit required documents listed in the
Instructions, USCIS may reject your notice.
Page 3 of 5Form I-865 07/17/15 N
Interpreter's Certification
I have read to this sponsor every question and instruction on
this notice, as well as the answer to every question, in the
language provided in Part 3., Item Number 1.b.; and
I certify that:
which is the same language provided in Part 3., Item Number
1.b.;
I am fluent in English and
The sponsor has informed me that he or she understands every
instruction and question on the notice, as well as the answer to
every question, and the sponsor verified the accuracy of every
answer.
,
Part 4. Interpreter's Contact Information,
Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Given Name (First Name)1.b.
Interpreter's Family Name (Last Name)1.a.
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Interpreter's Mailing Address
3.h.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f.
3.g.
Province
Street Number
and Name
3.a.
Country
3.b. Apt.
Flr.Ste.
Postal Code
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)5.
Interpreter's Signature
Date of Signature (mm/dd/yyyy)6.b.
Interpreter's Signature6.a.
Preparer's Mailing Address
3.c. City or Town
3.d. State 3.e. ZIP Code
Street Number
and Name
3.a.
3.b. Apt.
Flr.Ste.
3.h.
3.f.
Postal Code 3.g.
Country
Province
Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Notice, If Other Than the Sponsor
Preparer's Business or Organization Name (if any)2.
Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)1.b.
Provide the following information about the preparer.
Preparer's Contact Information
6. Preparer's Email Address (if any)
4. Preparer's Daytime Telephone Number
5. Preparer's Fax Number
Page 4 of 5Form I-865 07/17/15 N
I am not an attorney or accredited representative
but have prepared this notice on behalf of the
sponsor and with the sponsor's consent.
I am an attorney or accredited representative and
my representation of the sponsor in this case
7.a.
7.b.
Preparer's Statement
extends does not extend beyond the
preparation of this notice.
NOTE: If you are an attorney or accredited
representative whose representation extends
beyond preparation of this notice, you must
submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited
Representative, with this notice.
By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this notice on behalf of, at the request
of, and with the express consent of the sponsor. I completed
this notice based only on responses the sponsor provided to me.
After completing the notice, I reviewed it and all of the
sponsor's responses with the sponsor, who agreed with every
answer on the notice. If the sponsor supplied additional
information concerning a question on the notice, I recorded it on
the notice.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
Preparer's Signature
Part 5. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Notice, If Other Than the Sponsor
(continued)
Page 5 of 5Form I-865 07/17/15 N
Part 6.
Additional Information
If you need extra space to provide any additional information
within this notice, 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 notice or attach a separate sheet of
paper. Include your name 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.
1.b.
1.c.
1.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
3.d.
3.a.
Page Number
3.b.
Part Number
3.c.
Item Number
Page Number Part Number Item Number
5.d.
5.a.
Page Number
5.b.
Part Number
5.c.
Item Number
6.d.
6.a.
Page Number
6.b.
Part Number
6.c.
Item Number
Page Number Part Number Item Number
4.c.4.b.
4.d.
4.a.
2.c.2.b.2.a.
2.d.
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I-865 Application for Civil Surgeon Designation

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Completed 17 November 2019

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