Form I-131 12/23/16 N Page 5 of 5
To be completed by all preparers, including attorneys and
authorized representatives: I declare that I prepared this benefit
request at the request of the applicant, that it is based on all the
information of which I have knowledge, and that the
information is true to the best of my knowledge.
NOTE: If you require more space to provide any additional
information, use a separate sheet of paper. You must include
your Name and A-Number on the top of each sheet.
Part 9. Information About Person Who Prepared This Application, If Other Than the Applicant
Preparer's Full Name
Provide the following information concerning the preparer:
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
2. Preparer's Business or Organization Name
3.d. State 3.e. ZIP Code
3.f. Postal Code
Preparer's Contact Information
4. Preparer's Daytime Phone Number Extension
5. Preparer's E-mail Address (if any)
NOTE: If you are an attorney or representative, you must
submit a completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, along with this
Preparer's Mailing Address
3.c. City or Town
6.b. Date of Signature (mm/dd/yyyy) ►
I certify, under penalty of perjury under the laws of the
United States of America, that this application and the
evidence submitted with it is all true and correct. I
authorize the release of any information from my records
that U.S. Citizenship and Immigration Services needs
to determine eligibility for the benefit I am seeking.
Part 8. Signature of Applicant (Read the information on penalties in the Form instructions before completing
this Part.) If you are filing for a Re-entry Permit or Refugee Travel Document, you must be in the United States
to file this application.
NOTE: If you do not completely fill out this form or fail to
submit required documents listed in the instructions, your
application may be denied.
Signature of Applicant
1.b. Date of Signature (mm/dd/yyyy) ►
2. Daytime Phone Number