Form G-28 Notice Of Entry Of Appearance As Attorney Or Accredited Representative Page 2
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1
27.
Provide A-Number and/or Receipt Number
Part 3. Notice of Appearance as Attorney or
Accredited Representative
This appearance relates to immigration matters before
Pursuant to the Privacy Act of 1974 and DHS policy, I hereby
(select one):
consent to the disclosure to the named Attorney or Accredited
USCIS - List the form number(s)
Representative of any record pertaining to me that appears in
1.
any system of records of USCIS, ICE, or CBP.
1.a.
8.a. Signature of Applicant, Petitioner, or Respondent
2.
ICE - List the specific matter in which appearance is
entered
(mm/dd/yyyy) ►
8.b. Date
2.a.
3.
CBP - List the specific matter in which appearance is
Part 4. Signature of Attorney or Accredited
entered
Representative
3.a.
I have read and understand the regulations and conditions
contained in 8 CFR 103.2 and 292 governing appearances and
I hereby enter my appearance as attorney or accredited
representation before the Department of Homeland Security. I
representative at the request of:
declare under penalty of perjury under the laws of the United
States that the information I have provided on this form is true
Petitioner
Select only one:
Applicant
4.
and correct.
Respondent (ICE, CBP)
1.
Signature of Attorney or Accredited Representative
Name of Applicant, Petitioner, or Respondent
2.
Signature of Law Student or Law Graduate
5.a. Family Name
(Last Name)
5.b. Given Name
(mm/dd/yyyy) ►
(First Name)
3.
Date
5.c. Middle Name
Part 5. Additional Information
5.d. Name of Company or Organization, if applicable
1.
NOTE: Provide the mailing address of Petitioner, Applicant,or
Respondent and not the address of the attorney or accredited
representative, except when a safe mailing address is
permitted on an application or petition filed with Form G-28.
6.a. Street Number
and Name
6.b. Apt.
Ste.
Flr.
6.c. City or Town
6.d. State
6.e. Zip Code
Form G-28 02/28/13 N
Page 2 of 2
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