Form I-131a - Application For Travel Document (Carrier Documentation) Page 4

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Preparer's Statement
Part 6. Contact Information and Signature of the
Person Preparing this Application, if Other Than
7.a.
I am not an attorney or accredited representative but
the Applicant
have prepared this application on behalf of the
applicant and with the applicant's consent.
Provide the following information about the preparer.
7.b.
I am an attorney or accredited representative and my
representation of the applicant in this case
Preparer's Full Name
extends
does not extend beyond the
1.a. Preparer's Family Name (Last Name)
preparation of this application.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
1.b.
Preparer's Given Name (First Name)
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, or G-28I, Notice of Entry of
2.
Preparer's Business or Organization Name (if any)
Appearance as Attorney In Matters Outside the
Geographical Confines of the United States, with this
application.
Preparer's Mailing Address
Preparer's Certification
3.a.
Street Number
and Name
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
3.b.
Apt.
Ste.
Flr.
applicant then reviewed this completed application and
informed me that he or she understands all of the information
3.c. City or Town
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
3.d. State
3.e. ZIP Code
information is complete, true, and correct. I completed this
application based only on information that the applicant
3.f.
Province
provided to me or authorized me to obtain or use.
3.g.
Postal Code
Preparer's Signature
3.h. Country
8.a. Preparer's Signature
Preparer's Contact Information
8.b. Date of Signature (mm/dd/yyyy)
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Telephone Number (if any)
6.
Preparer's Email Address (if any)
Form I-131A 12/23/16 N
Page 4 of 5

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