Form I-485 - Supplement A - Adjustment Of Status Under Section 245(I) Page 4
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4Preparer's Statement
Part 6. Contact Information, Declaration, and
Signature of the Person Preparing this
I am not an attorney or accredited representative but
7.a.
Supplement, if Other Than the Applicant
have prepared this supplement on behalf of the
applicant and with the applicant's consent.
Provide the following information about the preparer.
I am an attorney or accredited representative and
7.b.
my representation of the applicant in this case
Preparer's Full Name
extends
does not extend beyond the
1.a. Preparer's Family Name (Last Name)
preparation of this supplement.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
1.b.
Preparer's Given Name (First Name)
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative, with this
supplement.
2.
Preparer's Business or Organization Name (if any)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
Preparer's Mailing Address
prepared this supplement at the request of the applicant. The
3.a.
Street Number
applicant then reviewed this completed supplement and
and Name
informed me that he or she understands all of the information
contained in, and submitted with, his or her supplement,
3.b.
Apt.
Ste.
Flr.
including the Applicant's Declaration and Certification, and
that all of this information is complete, true, and correct. I
3.c. City or Town
completed this supplement based only on information that the
applicant provided to me or authorized me to obtain or use.
3.d. State
3.e. ZIP Code
Preparer's Signature
3.f.
Province
8.a. Preparer's Signature (sign in ink)
3.g.
Postal Code
3.h. Country
8.b. Date of Signature (mm/dd/yyyy)
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Telephone Number (if any)
6.
Preparer's Email Address (if any)
Page 4 of 4
Form I-485 Supplement A 06/26/17 N
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