Form I-363 - Request To Enforce Affidavit Of Financial Support And Intent To Petition For Legal Custody For Public Law 97-359 Amerasian Page 3

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9.
Relationship of Applicant
Part 3. Other Information
Self
1.
Does the beneficiary live with the sponsor?
Yes
No
Representative of the Agency Having Legal Custody
of the Beneficiary
If you answered "No" to Item Number 1., provide the
Individual Having Legal Custody of the Beneficiary
name of the person with whom the beneficiary lives in
Item Numbers 2.a. - 2.c.
Guardian Ad Litem
2.a. Family Name
(Last Name)
2.b. Given Name
Part 4. Applicant's Statement, Contact
(First Name)
Information, Certification, and Signature
2.c. Middle Name
NOTE: Read the Penalties section of the Form I-363
3.
How is the beneficiary supported?
Instructions before completing this part.
Sponsor
Other Sources
Applicant's Signature
If the beneficiary is supported by the sponsor, how long
4.
has the sponsor supported the beneficiary?
Note: Select the box for either Item Number 1.a. or 1.b.
If applicable, select the box for Item Number 2.
Is the beneficiary in the legal custody of the sponsor?
5.
1.a.
I can read and understand English, and I have read
(Explain)
and understand every question and instruction on this
Yes
No
application and my answer to every question.
1.b.
The interpreter named in Part 5. read to me every
question and instruction on this application and my
answer to every question in
6.
Has the sponsor stopped all support?
Yes
No
,
a language in which I am fluent, and I understood
If you answered "Yes" to Item Number 6., provide the
everything.
date when the support stopped in Item Numbers 7.
2.
At my request, the preparer named in Part 6.,
7.
Date Support Stopped (mm/dd/yyyy)
,
8.
Has the sponsor given any reason for withdrawal of support?
prepared this application for me based only upon
Yes
No
information I provided or authorized.
If you answered "Yes" to Item Number 8., describe the
Applicant's Contact Information
circumstances under which the sponsor ceased his or her
support. If you need extra space to provide any additional
3.
Applicant's Daytime Telephone Number
information, use the space provided below in Part 7.
Additional Information.
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
NOTE: Attach a copy of Form I-361, Affidavit of Financial
Support and Intent to Petition for Legal Custody for P.L. 97-359
Amerasian, if available.
Form I-363 03/01/17 N
Page 3 of 7

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