Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 10

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Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor (continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this request at the request of the requestor. The requestor then
reviewed this completed request and informed me that he or she understands all of the information contained in, and submitted with,
his or her request, including the Applicant's Certification, and that all of this information is complete, true, and correct. I completed
this request based only on information that the requestor provided to me or authorized me to obtain or use.
Preparer's Signature
10.
Preparer's Signature
Date of Signature (mm/dd/yyyy)
Form I-912 04/25/16 Y
Page 10 of 11

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