Fillable I-941 Application for Entrepreneur Parole

Fill Online, Printable, Fillable, Blank I-941 Application for Entrepreneur Parole Form

Use Fill to complete blank online USCIS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

I-941 Application for Entrepreneur Parole

On average this form takes 103 minutes to complete

The I-941 Application for Entrepreneur Parole form is 21 pages long and contains:

  • 0 signatures
  • 140 check-boxes
  • 347 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your United States Citizenship and Immigration Services documents online.

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).

BROWSE USCIS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form I-941 04/24/19 Page 1 of 15
Application for Entrepreneur Parole
Department of Homeland Security
U.S. Citizenship and Immigration Services
For
USCIS
Use
Only
USCIS
Form I-941
OMB No. 1615-0136
Expires 04/30/2022
Action BlockReceipt
Remarks
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
Part 1. Information About the Entrepreneur
(Applicant)
3.b.
3.c.
3.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
►
Your Full Name
I am requesting:
Initial Parole
Re-Parole
1.c.
Amended Application
If you are requesting a re-parole or filing an amended application,
provide the Receipt Number of your current Form I-941 approval
in Item Number 2. below.
1.a.
1.b.
2.
OR
OR
8. Date of Birth (mm/dd/yyyy)
Sex Male Female9.
7.
USCIS Online Account Number (if any)6.
►
Other Information
5.
►
A-
Alien Registration Number (A-Number)
4.b.
4.c.
4.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Receipt Number
►
Other Names Used
Provide any other names you have used since birth, including
aliases, maiden names, and nicknames. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.
U.S. Social Security Number (if any)
►
10. Marital Status
WidowedDivorcedSingle Married
START HERE - Type or print in black ink.
Select this box if
Form G-28 or
G-28I is attached.
To be completed by an
attorney or accredited
representative (if any).
Form I-941 04/24/19 Page 2 of 15
Part 1. Information About the Entrepreneur
(Applicant) (continued)
Travel Document Number (if any)16.c.
Passport Number16.b.
16.d. Country of Issuance for Passport or Travel Document
16.e. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)
Date that Authorized Stay Expired or Will Expire as
Shown on Form I-94 or I-95 (mm/dd/yyyy)
16.f.
Provide information about your most recent Form I-94 Arrival-
Departure Record, in Item Numbers 16.a. - 16.f. (if any).
16.a. Form I-94 Arrival-Departure Record Number
►
17.a. Have you, or any person included in this application, ever
been in exclusion, deportation, removal, or rescission
proceedings, or are you now in such proceedings?
NoYes
19.a.
Entrepreneur's Current U.S. Mailing Address
In Care Of Name
ZIP Code
19.f.
State
19.e.
City or Town19.d.
Street Number
and Name
19.b.
19.c. Ste. Flr.Apt.
13. Date of Last Arrival in the United States (if any)
Current or Last Class of Admission (if any) (for example,
B-1, F-1, H-1B)
15. If you are present in the United States, other than on the
basis of an Entrepreneur Parole, provide the receipt number
of your most recent filing with USCIS (if applicable).
14.
11. Country of Birth
12. Country of Citizenship or Nationality
Name of DHS Office
To a Department of Homeland Security (DHS) office
overseas at:
►
Entrepreneur's Current Physical Address
ZIP Code
20.e.
State
20.d.
City or Town20.c.
20.f.
20.h.
Province
Country
Street Number
and Name
20.a.
20.b. Ste. Flr.
Apt.
Type of Degree/Major Field of Study22.
Date Degree Received (mm/dd/yyyy)23.
Entrepreneur's Education
21. Name of Institution of Higher Learning
Where do you want USCIS to send all travel documents for
you, and your spouse and dependent children (if applicable)?
18.a.
18.b.
18.c.
To the U.S. address in Part 1., Item Numbers
19.a. - 19.f.
To a U.S. Embassy or U.S. Consulate at:
Name of U.S. Embassy or U.S. Consulate
If you answered "Yes," to Item Number 17.a., provide
the following information below:
Name of the Person in Proceedings
17.b.
20.g.
Postal Code
(mm/dd/yyyy)
(USPS ZIP Code Lookup)
Form I-941 04/24/19 Page 3 of 15
24.c.
24.f.
24.h.
24.g.
24.d.
24.a.
24.b.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 24.e. ZIP Code
Province
Country
Postal Code
Part 1. Information About the Entrepreneur
(Applicant) (continued)
School Address
Part 2. Biographic Information
Not Hispanic or Latino
Hispanic or Latino
Ethnicity (Select only one box)
Race (Select all applicable boxes)
Native Hawaiian or Other Pacific Islander
Black or African American
American Indian or Alaska Native
Asian
White
Height Feet Inches
Weight Pounds
Black
Gray Green
Maroon Pink
Hazel
BrownBlue
Eye Color (Select only one box)
Unknown/Other
Hair Color (Select only one box)
Black
Brown
Red
White
Unknown/Other
Sandy
Gray
Blond
Bald (No hair)
1.
2.
3.
4.
5.
6.
Entrepreneur's Spouse's Information
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
1.a.
1.c.
1.b.
Part 3. Information About Family Members
Requesting Parole or Re-Parole with
Entrepreneur
USCIS Online Account Number (if any)3.
►
2.
►
A-
A-Number (if any)
4. Date of Birth (mm/dd/yyyy)
5.
Country of Citizenship or Nationality6.
Country of Birth
Provide the following information about each child. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
8.a. Family Name
(Last Name)
8.b. Given Name
(First Name)
Middle Name
8.c.
Child 1
Entrepreneur's Dependent Children
Entrepreneur's Spouse's Other Names Used
Provide any other names your spouse has used since birth,
including aliases, maiden names, and nicknames. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
Middle Name
Given Name
(First Name)
Family Name
(Last Name)
7.a.
7.c.
7.b.
Form I-941 04/24/19 Page 4 of 15
11. Date of Birth (mm/dd/yyyy)
12. Country of Birth
USCIS Online Account Number (if any)10.
►
14.a. Family Name
(Last Name)
14.b. Given Name
(First Name)
Middle Name
14.c.
Child 2
15.
►
A-
A-Number (if any)
USCIS Online Account Number (if any)16.
►
17. Date of Birth (mm/dd/yyyy)
18. Country of Birth
9.
►
A-
A-Number (if any)
Part 3. Information About Family Members
Requesting Parole or Re-Parole with
Entrepreneur (continued)
Part 4. Information About Additional
Entrepreneurs Requesting or Have Been Granted
Parole or Re-Parole with the Same Start-up
Entity
1.a. Family Name
(Last Name)
1.b. Given Name
(First Name)
Middle Name1.c.
Entrepreneur 1
2. Date of Birth (mm/dd/yyyy)
5.a. Family Name
(Last Name)
5.b. Given Name
(First Name)
Middle Name5.c.
8. Receipt Number (if applicable)
►
Entrepreneur 2
6. Date of Birth (mm/dd/yyyy)
Country of Citizenship or Nationality7.
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners
Information About the Qualifying Start-Up Entity
Start-Up Entity Legal Name
2.a.
2.b.
2.c.
2.d.
Start-Up Entity Address
1.
ZIP Code2.e.State
City or Town
Street Number
and Name
Ste. Flr.Apt.
3.
DUNS Number (if any)4.
Trade Name "DBA" (Doing Business As)5.
Federal Employer Identification Number
Date Start-Up Entity Established in United States6.
(mm/dd/yyyy)
7. Number of Full-Time Employees in United States
Country of Citizenship or Nationality13.
4. Receipt Number (if applicable)
►
Country of Citizenship or Nationality19.
Country of Citizenship or Nationality3.
Form I-941 04/24/19 Page 5 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
9. Explanatory Statement. Provide a detailed statement
explaining how you meet the criteria for entrepreneur
parole. Your statement should include an explanation of
your role in the operations of that entity, as well as how
your involvement with the start-up entity will advance the
start-up entity's growth and business success such as to
result in a significant public benefit. You may provide this
statement in the space provided in Part 10. Additional
Information or attach a separate sheet of paper; type or
print your name and startup entity identification number 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.
NoYes
Did your start-up entity receive a qualified investment of
at least $250,000 within 18 months immediately
preceding the filing of this application?
10.a.
Amount of Qualified Investment
$
Amount of Qualified Government Award or Grant
$
No N/AYes
Does your start-up entity partially meet one or both of the
above threshold criteria?
12.a.
12.b.
12.c.
If you answered "No" to Item Number 13., explain the
current status of the start-up entity for which you were
granted initial parole in Item Number 14. If you need
more space to complete this section, use the space
provided in Part 10. Additional Information.
Is this the same start-up entity for which you were granted
an initial parole?
NoYes
13.
14.
Explanation
Amount of Qualified Investment
$
If you answered "Yes" to Item Number 10.a., provide
the amount of qualified investment and date the qualified
investment was received in Item Numbers 10.b. - 10.c.
Date Qualified Investment Received (mm/dd/yyyy)
10.b.
10.c.
NoYes
Did your start-up entity receive a qualified government
award or grant of at least $100,000 within 18 months
immediately preceding the filing of this application?
11.a.
Alternative Criteria
Provide evidence that you continue to meet the definition of
entrepreneur and that your business continues to meet the
definition of start-up entity.
Do you own at least 5% of the shares, or similar type of
equity interest, in the start-up entity?
NoYes
15.
Re-Parole Criteria
If you answered "Yes" to Item Number 11.a., provide
the amount of qualified government award or grant and
date the qualified government award or grant was
received in Item Numbers 11.b. - 11.c.
Applying for Initial Parole
If you answered "Yes" to Item Number 12.a., provide
the amounts of qualified investment and/or qualified
government award or grant that was received in Item
Numbers 12.b. - 12.c.
Applying for Re-Parole
Date Qualified Grant or Award Received (mm/dd/yyyy)11.c.Your Ownership Stake/Percentage of Start-Up Entity8.
%
Amount of Qualified Government Award or Grant
$
11.b.
If you need more space to complete this section, use the
space provided in Part 10. Additional Information.
If you need more space to complete this section, use the
space provided in Part 10. Additional Information.
Form I-941 04/24/19 Page 6 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
18.b.
$
Provide the amounts of qualifying investments, qualified
government awards or grants.
19.a. Did your start-up entity create at least 10 qualified jobs
with the start-up entity during the initial parole period?
N/AYes No
20.a. Did your start-up reach at least $500,000 in annual revenue
in the United States during the initial parole period?
N/AYes No
23.
Provide a detailed statement explaining how you continue
to meet the criteria for entrepreneur parole. Your statement
should include an explanation of your continued or new
role in the operations of that entity, as well as how your
involvement with the start-up entity will advance the start-
up entity's growth and business success such as to result in
a significant public benefit. You may provide this
statement in the space provided in Part 10. Additional
Information or attach a separate sheet of paper; type or
print your name and startup entity identification number 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.
Provide the amount of annual revenue generated.
$
20.b.
Provide the percentage of annual revenue growth.21.b.
21.a. Did the annual revenue generated by your start-up entity in
the United States average 20 percent growth during the
initial parole period?
N/AYes No
Are you maintaining a household income that is greater
than 400 percent of the Federal Poverty Guidelines?
NoYes
24.a.
Amount of Household Income in Last Full Calendar Year
$
24.b.
Number of Members of Household24.c.
18.a. Did your start-up entity receive at least $500,000 in
qualifying investments, qualified government awards or
grants, or a combination of such funding during the initial
parole period?
N/AYes No
Provide the number of qualified jobs.19.b.
%
22.a. Does your start-up entity partially meet one or more of the
above threshold criteria?
N/AYes No
Alternative Criteria
If you answered "Yes" to Item Number 22.a., provide
the applicable information requested in Item Numbers
22.b. - 22.d.
22.b.
Total Amount of Additional Qualified Investment,
Government Grants or Awards During Initial Period of
Parole
$
22.c.
$
Total Amount of Revenue Generated During Initial
Period of Parole
Total Number of Qualified Jobs Created During Initial
Period of Parole
22.d.
If you answered "Yes" to Item Number 24.a., provide
the information requested in Item Numbers 24.b. - 24.c.
Filing an Amended Application to Report a
Material Change
In the space below, provide a detailed explanation of any material
changes to the facts on which your parole was based. If you need
more space to complete this section, use the space provided in
Part 10. Additional Information.
25.
Explanation
Do you continue to perform an active and central role in
the start-up entity?
16.
Is the start-up entity continuing to lawfully operate in the
United States?
NoYes
17.
Yes No
Form I-941 04/24/19 Page 7 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
Are you maintaining a household income that is greater
than 400 percent of the Federal Poverty Guidelines?
NoYes
26.a.
Amount of Household Income in Last Full Calendar Year
$
26.b
Number of Members of Household26.c.
Information About the Owners of the Start-Up
Entity
If there are multiple owners of the start-up entity, you must list
all other individuals or entities that own a share of the start-up
entity and identify their ownership percentage.
27.a. Family Name
(Last Name)
27.b. Given Name
(First Name)
Middle Name
27.c.
27.d. Legal Entity Name (if any)
27.e. Trade Name "DBA" (Doing Business As)
32. Date of Birth (mm/dd/yyyy)
33.
Country of Citizenship or Nationality34.
Country of Birth
USCIS Online Account Number (if any)31.
►
35.a. Percentage of Ownership in the Start-Up Entity Listed in
Part 5., Item Number 1.
35.b. Position Held (if any) in the Entity Listed in Part 5., Item
Number 1.
Address and Contact Information
36.d.
36.c.
36.g.
36.h.
36.f.
36.a.
36.b.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 36.e. ZIP Code
Province
Country
Postal Code
If you answered "Yes" to Item Number 26.a., provide
the information requested in Item Numbers 26.b. - 26.c.
Owner 1
Provide any other names you have used since birth, including
aliases, maiden names, and nicknames. If you need extra space
to complete this section, use the space provided in Part 10.
Additional Information.
28.b.
28.c.
28.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Other Names Used
Other Information
29.
►
A-
A-Number (if any)
U.S. Social Security Number (if any)30.
►
39.
Email Address (if any)
Fax Number38.
Daytime Telephone Number37.
40.
Website Address (if any)
Owner 2
41.a. Family Name
(Last Name)
41.b. Given Name
(First Name)
Middle Name41.c.
Form I-941 04/24/19 Page 8 of 15
Part 5. Basis of Eligibility - Qualifying Start-Up
Entity and Owners (continued)
41.d. Legal Entity Name (if any)
41.e. Trade Name "DBA" (Doing Business As)
Provide any other names used for Owner 2 since birth,
including aliases, maiden name, and nicknames. If extra space
is needed to complete this section, use the space provided in
Part 10. Additional Information.
Other Names Used
42.b.
42.c.
42.a. Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Other Information
43.
►
A-
A-Number (if any)
U.S. Social Security Number (if any)44.
►
USCIS Online Account Number (if any)45.
►
46. Date of Birth (mm/dd/yyyy)
47. Country of Birth
Address and Contact Information
50.d.
50.c.
50.g.
50.h.
50.f.
50.a.
50.b.
Fax Number52.
Daytime Telephone Number51.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 50.e. ZIP Code
Province
Country
Postal Code
53.
Email Address (if any)
54.
Website Address (if any)
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
1.a.
1.b.
1.c.
2.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Date of Birth (mm/dd/yyyy)
3.
►
A-
A-Number (if any)
Name of Investor (if an individual)
Country of Citizenship or Nationality48.
49.a. Percentage of Ownership in the Start-Up Entity Listed in
Part 5., Item Number 1.
49.b. Position Held (if any) in the Entity Listed in Part 5., Item
Number 1.
U.S. Social Security Number (if any)4.
►
5. Country of Birth
Form I-941 04/24/19 Page 9 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
Mailing Address and Contact Information
Fax Number
Daytime Telephone Number
Email Address (if any)
Website Address (if any)
6.a.
6.b.
6.c.
6.d.
6.f.
6.g.
6.h.
7.
8.
9.
10.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 6.e. ZIP Code
Province
Country
Postal Code
11.a.
Types of Investment (for example, equity or convertible
debt)
11.b.
Aggregate Amount of Investment
List investments in other start-ups by this investor during the
preceding five years totaling no less than $600,000. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
17. $Amount of Investment
14.
Type of Investment18.
Year of Investment16.
Name of Company
DUNS Number (if any)15.
19.a.
19.b.
19.c.
19.d.
19.f.
19.g.
19.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 19.e. ZIP Code
Province
Country
Postal Code
Identify at least 2 of the start-ups listed above that each created,
subsequent to such investment, at least 5 qualified jobs or
generated at least $500,000 in revenue with average annualized
revenue growth of at least 20 percent.
20. Name of Company
Is the investor a U.S. citizen or lawful permanent resident
of the United States?
12.
NoYes
Qualified Investor Verification
DUNS Number (if any)21.
Information on Investment
$
Yes No
Has the investor been permanently or temporarily enjoined
from participating in the offer or sale of a security or in the
provision of services as an investment adviser, broker,
dealer, municipal securities dealer, government securities
broker, government securities dealer, bank, transfer agent
or credit rating agency; barred from association with any
entity involved in the offer or sale of securities or provision
of such services; or otherwise found to have participated in
the offer or sale of securities or provision of such services
in violation of law?
13.
Company 1
Form I-941 04/24/19 Page 10 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
22.a.
22.b.
22.c.
22.d.
22.f.
22.g.
22.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 22.e. ZIP Code
Province
Country
Postal Code
23. Name of Company
DUNS Number (if any)24.
25.a.
25.b.
25.c.
25.d.
25.f.
25.g.
25.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 25.e. ZIP Code
Province
Country
Postal Code
27.a.
27.b.
27.c.
27.d.
27.f.
27.g.
27.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 27.e. ZIP Code
Province
Country
Postal Code
Fax Number
Daytime Telephone Number
Email Address (if any)
Website Address (if any)
28.
29.
30.
31.
32.a.
Types of Investment (for example, equity or
convertible debt)
32.b.
Aggregate Amount of Investment
Address and Contact Information
Company 2
Name of Investor (if an organization such as a
Venture Capital Firm, Accelerator or Incubator)
Legal Entity Name26.a.
Trade Name "DBA" (Doing Business As)26.b.
DUNS Number (if any)26.c.
Information on Investment
$
Is the investor majority owned and controlled, directly
and indirectly, by U.S. citizens or lawful permanent
residents of the United States?
33.
NoYes
Qualified Investor Verification
Yes No
Has the investor been permanently or temporarily enjoined
from participating in the offer or sale of a security or in the
provision of services as an investment adviser, broker,
dealer, municipal securities dealer, government securities
broker, government securities dealer, bank, transfer agent
or credit rating agency; barred from association with any
entity involved in the offer or sale of securities or
provision of such services; or otherwise found to have
participated in the offer or sale of securities or provision of
such services in violation of law?
34.
Form I-941 04/24/19 Page 11 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
List investments in other start-ups by this investor during the
preceding five years totaling no less than $600,000. If you need
extra space to complete this section, use the space provided in
Part 10. Additional Information.
38. $Amount of Investment
35.
Type of Investment39.
Year of Investment37.
Name of Company
DUNS Number (if any)36.
40.a.
40.b.
40.c.
40.d.
40.f.
40.g.
40.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 40.e. ZIP Code
Province
Country
Postal Code
43.a.
43.b.
43.c.
43.d.
43.f.
43.g.
43.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 43.e. ZIP Code
Province
Country
Postal Code
44. Name of Company
DUNS Number (if any)45.
46.a.
46.b.
46.c.
46.d.
46.f.
46.g.
46.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 46.e. ZIP Code
Province
Country
Postal Code
Address Information
Company 1
Identify at least 2 of the start-ups listed above that each created,
subsequent to such investment, at least 5 qualified jobs or
generated at least $500,000 in revenue with average annualized
revenue growth of at least 20 percent.
41. Name of Company
DUNS Number (if any)42.
Company 2
Form I-941 04/24/19 Page 12 of 15
Part 6. Information on Qualified Investors or
Government Entities Providing a Grant/Award
(continued)
48.a.
48.b.
48.c.
48.d.
48.f.
48.g.
48.h.
Street Number
and Name
Apt. Ste. Flr.
City or Town
State 48.e. ZIP Code
Province
Country
Postal Code
Fax Number
Daytime Telephone Number
Email Address (if any)
49.
50.
51.
Website Address (if any)
52.
53.a.
Types of Grant/Award53.b.
Aggregate of Amount of Grant/Award
I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.
1.a.
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
NOTE: Read the Penalties section of the Form I-941
Instructions before completing this part. You must file Form
I-941 while in the United States.
Applicant's Statement
a language in which I am fluent, and I understood.
The interpreter named in Part 8. read to me every
question and instruction on this application and my
answer to every question in
1.b.
,
2. At my request, the preparer named in Part 9.,
,
prepared this application for me based upon
information I provided or authorized.
Address and Contact Information
Applicant's Daytime Telephone Number
Applicant's Contact Information
Applicant's Mobile Telephone Number (if any)
Applicant's Email Address (if any)
4.
3.
5.
Applicant's Declaration and 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 and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS
records, to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
$
Name of Government Entity Providing Grant/Award
Name of Approving Official47.
Information on Grant/Award
Form I-941 04/24/19 Page 13 of 15
Part 7. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature (continued)
I understand that USCIS will require me to appear for an
appointment to take my biometrics (fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an
oath reaffirming that:
1) I reviewed and understood all of the information
contained in, and submitted with, my application; and
2) All of this information was complete, true, and correct
at the time of filing.
I certify, under penalty of perjury, that all of the information in
my application and any document submitted with it were
provided or authorized by me, that I reviewed and understand
all of the information contained in, and submitted with, my
application and that all of this information is complete, true, and
correct.
NOTE TO ALL APPLICANTS: If you do not completely fill
out this application or fail to submit required documents listed
in the Instructions, USCIS may deny your application. USCIS
may terminate your parole, granted pursuant to this rule, if you
fail to submit the required information or upon a determination
that your continued presence in the United States no longer
provides a significant public benefit.
Date of Signature (mm/dd/yyyy)6.b.
Applicant's Signature6.a.
Applicant's Signature
Part 8. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Family Name (Last Name)1.a.
Interpreter's Full Name
Interpreter's Given Name (First Name)1.b.
Interpreter's Business or Organization Name (if any)2.
Provide the following information about the interpreter.
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. Flr.Apt. Ste.
3.g.
3.h. Country
Province
Interpreter's Contact Information
4.
Interpreter's Mobile Telephone Number (if any)5.
Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any) 6.
Interpreter's Certification
I certify, under penalty of perjury, that:
which is the same language specified in Part 7., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
Certification, and has verified the accuracy of every answer.
I am fluent in English and ,
Interpreter's Signature7.a.
Date of Signature (mm/dd/yyyy)7.b.
Interpreter's Signature
Form I-941 04/24/19 Page 14 of 15
Part 9. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Business or Organization Name (if any)2.
Preparer's Given Name (First Name)1.b.
Preparer's Full Name
Provide the following information about the preparer.
1.a. Preparer's Family Name (Last Name)
NOTE: If applicable, provide the name of your accredited
organization recognized by the Board of Immigration Appeals
(BIA).
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. Flr.Apt. Ste.
3.g.
3.h. Country
Province
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
5. Preparer's Mobile Telephone Number
6. Preparer's Email Address (if any)
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
7.a.
7.b.
preparation of this application.
Preparer's Statement
does not extend beyond the extends
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, or Form
G-28I, Notice of Entry of Appearance as Attorney In
Matters Outside the Geographical Confines of the
United States, with this application.
8.a. Preparer's Signature
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Certification
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 application and
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
completed this application based only on information that the
applicant provided to me or authorized me to obtain or use.
Preparer's Signature
Form I-941 04/24/19 Page 15 of 15
Part 10. 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 the start-up entity's 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.
3.a. 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
7.a. 7.b. 7.c.
Item NumberPart NumberPage Number
5.b.
Part Number
5.c.
Item Number
5.d.
4.c.4.b.
4.d.
4.a.
6.d.
7.d.
6.c.6.b.6.a.
Name of Start-Up Entity
2. Start-Up Entity Identification Number
1.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

I-941 Application for Entrepreneur Parole

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 17 November 2019

Message

View Audit Log
Print With Audit Log
Duplicate Document