Form I-485 - Application To Register Permanent Residence Or Adjust Status Page 17
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A-Number
A-
Part 12. Contact Information, Declaration, and
NOTE: Do not complete Part 13. until the USCIS Officer
instructs you to do so at the interview.
Signature of the Person Preparing this
Application, if Other Than the Applicant
(continued)
Part 13. Signature at Interview
I swear (affirm) and certify under penalty of perjury under the
Preparer's Statement
laws of the United States of America that I know that the
I am not an attorney or accredited representative
contents of this Form I-485, Application to Register Permanent
7.a.
but have prepared this application on behalf of
Residence or Adjust Status, subscribed by me, including the
the applicant and with the applicant's consent.
corrections made to this application, numbered
I am an attorney or accredited representative and
7.b.
through
, are complete, true, and correct. All
my representation of the applicant in this case
additional pages submitted by me with this Form I-485, on
extends
does not extend beyond the
preparation of this application.
numbered pages
through
are complete,
NOTE: If you are an attorney or accredited
true, and correct. All documents submitted at this interview
representative, you may be obliged to submit a
were provided by me and are complete, true, and correct.
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Subscribed to and sworn to (affirmed) before me
Representative, with this application.
USCIS Officer's Printed Name or Stamp
Preparer's Certification
Date of Signature (mm/dd/yyyy)
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
Applicant's Signature (sign in ink)
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,
USCIS Officer's Signature (sign in ink)
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
8.a. Preparer's Signature (sign in ink)
8.b. Date of Signature (mm/dd/yyyy)
Form I-485 06/26/17 N
Page 17 of 18
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