Form N-648 - Medical Certification For Disability Exceptions - U.s. Department And Immigration Services Page 5

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Applicant's Name
USCIS A-Number
A-
12. Was an interpreter used during your examination of the applicant?
Yes (If "Yes," the interpreter must complete the "Interpreter Certification" section.)
No
Additional Comments (Optional)
MEDICAL PROFESSIONAL' S CERTIFICATION
Complete the following if an interpreter was not used during your examination of the applicant between the applicant and medical professional
pertaining to the examinations that form the basis of this Form N-648.
I am fluent in English and
, the language spoken by this patient. Therefore, an interpreter was not used during
my examinations of this applicant.
All medical professionals must complete the certification below.
I certify that this applicant's identity has been verified through the following United States or State government-issued photographic
identity document:
Permanent Resident Card
State ID Number:
Other Identification (Indicate type and ID Number):
I certify, under penalty of perjury under the laws of the United States of America, that the information on this form and any evidence submitted
with it are all true and correct. I will furnish relevant medical records to USCIS, if requested to do so by USCIS, based on the applicant's consent.
I am aware that the knowing placement of false information on Form N-648 and related documents may also subject me to criminal penalties
including under 18 U.S.C. section 1546, civil penalties under 8 U.S.C. section 1324c and Immigration and Nationality Act (INA) section 274C,
and civil license suspension or revocation by the appropriate authorities.
Licensed Medical Professional Signature
Date (mm/dd/yyyy)
Form N-648 03/21/17 Y Page 5

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