Form I-130a - Supplemental Information For Spouse Beneficiary Page 3
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2
3
4
5
6The interpreter named in Part 5. read to me every
1.b.
Part 2. Information About Your Employment
question and instruction on this form and my answer
(continued)
to every question in
7.
Your Occupation
,
a language in which I am fluent, and I understood
everything.
8.a.
Date From (mm/dd/yyyy)
2.
At my request, the preparer name in Part 6.,
8.b.
Date To (mm/dd/yyyy)
,
prepared this form for me based only upon
information I provided or authorized.
Part 3. Information About Your Employment
Outside the United States
Spouse Beneficiary's Contact Information
Provide your last occupation outside the United States if not
3.
Spouse Beneficiary's Daytime Telephone Number
shown above. If you never worked outside the United States,
provide this information in the space provided in Part 7.
Additional Information.
4.
Spouse Beneficiary's Mobile Telephone Number (if any)
1.
Name of Employer/Company
5.
Spouse Beneficiary's Email Address (if any)
2.a.
Street Number
and Name
2.b.
Apt.
Ste.
Flr.
Spouse Beneficiary's Certification
2.c.
City or Town
Copies of any documents I have submitted are exact photocopies
of unaltered, original documents, and I understand that USCIS
2.d.
2.e.
State
ZIP Code
may require that I submit original documents to USCIS at a later
date. Furthermore, I authorize the release of any information
2.f.
Province
from any of my records that USCIS may need to determine my
eligibility for the immigration benefit I seek.
2.g. Postal Code
I further authorize release of information contained in this form,
2.h.
Country
in supporting documents, and in my USCIS records to other
entities and persons where necessary for the administration and
enforcement of U.S. immigration laws.
3.
Your Occupation
I certify, under penalty of perjury, that I provided or authorized
all of the information in this form, I understand all of the
information contained in, and submitted with, my form, and that
4.a.
Date From (mm/dd/yyyy)
all of this information is complete, true, and correct.
4.b.
Date To (mm/dd/yyyy)
Spouse Beneficiary's Signature
6.a.
Spouse Beneficiary's Signature (sign in ink)
Part 4. Spouse Beneficiary's Statement, Contact
Information, Certification, and Signature
6.b.
Date of Signature (mm/dd/yyyy)
NOTE: Read the Penalties section of the Form I-130 and
Form I-130A Instructions before completing this part.
NOTE TO ALL SPOUSE BENEFICIARIES: If you do not
completely fill out this form or fail to submit required documents
Spouse Beneficiary's Statement
listed in the Instructions, USCIS may deny the Form I-130 filed
NOTE: Select the box for either Item Number 1.a. or 1.b. If
on your behalf.
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
and understand every question and instruction on this
form and my answer to every question.
Form I-130A 02/27/17 N
Page 3 of 6
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