Form I-360 - Petition For Amerasian, Widow(Er), Or Special Immigrant Page 16
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19Part 12. Statement, Contact Information, Declaration, and Signature of the Petitioner or Authorized
Signatory (continued)
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.
Authorized Signatory's Contact Information
3.
Authorized Signatory's Family Name (Last Name)
Authorized Signatory's Given Name (First Name)
4.
Authorized Signatory's Title
5.
Authorized Signatory's Daytime Telephone Number
6.
Authorized Signatory's Mobile Telephone Number (if any)
7.
Authorized Signatory's Email Address (if any)
Petitioner's or Authorized Signatory's Declaration and Certification
Copies of any documents submitted are exact photocopies of unaltered, original documents, and I understand that, as the petitioner, I
may be required to submit original documents to USCIS at a later date.
I authorize the release of any information from my records, or from the petitioning organization's records, to USCIS or other entities
and persons where necessary to determine eligibility for the immigration benefit sought or where authorized by law. I recognize the
authority of USCIS to conduct audits of this petition using publicly available open source information. I also recognize that any
supporting evidence submitted in support of this petition may be verified by USCIS through any means determined appropriate by
USCIS, including but not limited to, on-site compliance reviews.
If filing this petition on behalf of an organization, I certify that I am authorized to do so by the organization.
I certify, under penalty of perjury, that I have reviewed this petition, I understand all of the information contained in, and submitted
with, my petition, and all of this information is complete, true, and correct.
Petitioner's or Authorized Signatory's Signature
8.
Petitioner's or Authorized Signatory's Signature
Date of Signature (mm/dd/yyyy)
NOTE TO ALL PETITIONERS AND AUTHORIZED SIGNATORIES: If you do not completely fill out this petition or fail to
submit required documents listed in the Instructions, USCIS may delay a decision on or deny your petition.
Form I-360 12/23/16 N
Page 16 of 19
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