Part 14. Contact Information, Declaration, and Signature of the Person Preparing this Petition, if Other
Than the Petitioner
Provide the following information about the preparer.
Preparer's Full Name
1.
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
2.
Preparer's Business or Organization Name (if any)
Preparer's Mailing Address
Street Number and Name
Apt.
Ste.
Flr. Number
3.
City or Town
State
ZIP Code
Province
Postal Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Number
6.
Preparer's Email Address (if any)
Preparer's Statement
7.
A.
I am not an attorney or accredited representative but have prepared this petition on behalf of the
petitioner and with the petitioner's consent.
B.
I am an attorney or accredited representative and my representation of the petitioner in this case
extends
does not extend beyond the preparation of this petition.
NOTE: If you are an attorney or accredited representative whose representation extends beyond
preparation of this petition, you may be obliged to submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited Representative, or G-28I, Notice of Entry of Appearance
as Attorney In Matters Outside the Geographical Confines of the United States, with this petition.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this petition at the request of the petitioner or authorized signatory.
The petitioner has reviewed this completed petition, including the Petitioner's Declaration and Certification, or Petitioner's or
Authorized Signatory's Declaration and Certification, and informed me that all of this information in the form and in the
supporting documents is complete, true, and correct.
Preparer's Signature
8.
Preparer's Signature (sign in ink)
Date of Signature (mm/dd/yyyy)
Form I-360 12/23/16 N
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