Form I-102 - Application For Replacement/initial Nonimmigrant Arrival-Departure Document - U.s. Citizenship And Immigration Services Page 4

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Part 5. Contact Information, Certification, and
Preparer's Contact Information
Signature of the Interpreter (continued)
4.
Preparer's Daytime Telephone Number
Interpreter Certification
I certify that:
5.
Preparer's Fax Number
,
I am fluent in English and
which
is the same language provided in Part 4., Item Number 1.b.;
6.
Preparer's E-mail Address
I have read to this applicant every question and instruction on
this form, as well as the answer to every question, in the
I am not an attorney or accredited representative but
language provided in Part 4., Item Number 1.b.; and
7.a.
have prepared this form on behalf of the applicant
The applicant has informed me that he or she understands every
and with the applicant's consent.
instruction and question on the form, as well as the answer to
I am an attorney or accredited representative and my
7.b.
every question.
representation of the applicant in this case
6.a.
Interpreter's Signature
(choose one) extends
does not extend
beyond the preparation of this form.
6.b.
Date of Signature
(mm/dd/yyyy)
Preparer's Declaration
By my signature, I certify, swear, or affirm, under penalty of
Part 6. Contact Information, Declaration, and
perjury, that I prepared this form on behalf of, at the request of,
Signature of the Person Preparing this
and with the express consent of the applicant. I completed the
form based only on responses the applicant provided to me.
Application, If Other than the Applicant
After completing the form, I reviewed it and all of the
applicant's responses with the applicant, who agreed with every
Preparer's Full Name
answer provided for every question on the form and, when
required, supplied additional information to respond to a
Provide the following information concerning the preparer:
question on the form.
1.a. Preparer's Family Name (Last Name)
8.a. Preparer's Signature
1.b.
Preparer's Given Name (First Name)
8.b. Date of Signature (mm/dd/yyyy) ►
2.
Preparer's Business or Organization Name
NOTE: If you need extra space to provide any additional
information, attach a separate sheet of paper; type or print your
name and A-Number (if any) at the top of each sheet; indicate
the Page Number, Part Number, and Item Number to which
Preparer's Mailing Address
your answer refers; and date and sign each sheet.
3.a.
Street Number
and Name
3.b. Apt.
Ste.
Flr.
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f.
Province
3.g. Postal Code
3.h.
Country
Form I-102 12/23/16 N
Page 4 of 4

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