Form I-360 - Petition For Amerasian, Widow(Er), Or Special Immigrant Page 13

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Part 9. Complete Only If Filing a Special Immigrant Religious Worker Petition (continued)
Information About the Attesting Religious Organization Within the Religious Denomination
24.
Name of Attesting Religious Organization Within the Religious Denomination
25.
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
26.
Daytime Telephone Number
27.
Fax Number (if any)
28.
Email Address (if any)
29.
IRS Tax Number of the Attesting Religious Organization
Part 10. Complete Only If Filing as a VAWA Self-Petitioning Spouse or Child of a U.S. Citizen or
Lawful Permanent Resident or a VAWA Self-Petitioning Parent of a U.S. Citizen Son or Daughter
NOTE: For the safety and protection of all VAWA self-petitioners, information regarding a filing will only be provided to the
self-petitioner or their designated attorney or representative with a valid Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative.
1.
Full Name of U.S. citizen or Lawful Permanent Resident Abuser
Family Name (Last Name)
Given Name (First Name)
Middle Name
2.
Date of Birth (mm/dd/yyyy)
3.
Country of Birth
4.
Date of Death (mm/dd/yyyy)
5.
Your abuser is now, or was, a (Select one):
A.
U.S. citizen born in the United States
B.
U.S. citizen born abroad to U.S. citizen parents
C.
U.S. citizen through naturalization
(1)
Provide A-Number (if known)
A-
D.
U.S. Lawful Permanent Resident
A-
(1)
Provide A-Number (if any)
E.
Other (Explain)
6.
How many times have you been married?
7.
How many times was your abuser married (if known)?
Form I-360 12/23/16 N
Page 13 of 19

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