Form I-360 - Petition For Amerasian, Widow(Er), Or Special Immigrant Page 14

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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
(continued)
8.
A.
When did you and your abuser get married? (If you are a self-petitioning child or self-petitioning parent, type or print "N/A.")
(mm/dd/yyyy)
B. Where did you and your abuser get married? (If you are a self-petitioning child or self-petitioning parent, type or print "N/A.")
9.
When did you live with your abuser?
From (mm/dd/yyyy)
To (mm/dd/yyyy)
Include any other dates you have lived off/on with your abuser in the space provided in Part 15. Additional Information.
10.
Provide the last address at which you lived together with your abuser.
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
11.
Provide the last date that you lived together with your abuser at this address.
From (mm/dd/yyyy)
To (mm/dd/yyyy)
12.
I am currently residing in the United States and I request an Employment Authorization Document.
Yes
No
Part 11. Petitioner's Statement, Contact Information, Declaration, and Signature (Individual)
IMPORTANT: Complete this section ONLY if you are an individual filing this petition for yourself. If you are filing Form I-360 to
petition for another person or as an authorized signatory of an organization, complete Part 12. Statement, Contact Information,
Declaration, and Signature of the Petitioner or Authorized Signatory.
NOTE: Read the Penalties section of the Form I-360 Instructions before completing this part.
Petitioner's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.
Petitioner's Statement Regarding the Interpreter
A.
I can read and understand English, and I have read and understand every question and instruction on this petition and
my answer to every question.
B.
The interpreter named in Part 13. read to me every question and instruction on this petition and my answer to every
question in
,
a language in which I am fluent. I understand all of this information as interpreted.
2.
Petitioner's Statement Regarding the Preparer
At my request, the preparer named in Part 14.,
,
prepared this petition for me based only upon information I provided or authorized.
Form I-360 12/23/16 N
Page 14 of 19

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