Part 7. Name, Contact Information, Statement, Certification, and Signature of the Person Preparing
this Supplement, If Other Than the Adult Member of the Household, and/or Applicant or Petitioner
(continued)
Preparer's Mailing Address
3.
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Fax Number (if any)
6.
Preparer's Email Address (if any)
Preparer's Statement
7.A.
I am not an attorney or accredited representative but have prepared this supplement on behalf of the adult member of the
household and/or applicant or petitioner and with the adult member of the household's and/or applicant's or petitioner's
consent.
7.B.
I am an attorney or accredited representative and my representation of the adult member of the household and/or applicant
or petitioner in this case
extends
does not extend beyond the preparation of this supplement.
NOTE: If you are an attorney or accredited representative whose representation extends beyond the preparation of this
supplement, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, or Form G-28I, Notice of Entry of Appearance as Attorney in Matters Outside the Geographical Confines of
the United States, with this supplement.
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this supplement on behalf of, at the request of,
and with the express consent of the adult member of the household and/or applicant or petitioner. I completed this supplement based
only on responses the adult member of the household and/or applicant or petitioner provided to me. After completing the supplement,
I reviewed it and all of the adult member of the household's and/or applicant's or petitioner's responses with the adult member of the
household and/or applicant or petitioner, who agreed with every answer on the supplement. If the adult member of the household and/
or applicant or petitioner supplied additional information concerning a question on the supplement, I recorded it on the supplement.
Preparer's Signature
8.
Preparer's Signature
Date of Signature
(mm/dd/yyyy)
Form I-600A/I-600 Supplement 1 12/23/16 N
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