Form I-687 - Application For Status As A Temporary Resident Under Section 245a Of The Immigration And Nationality Act Page 9

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47. Signature and Certification of Applicant (Sign below)
I CERTIFY, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. I
hereby consent and authorize U.S. Citizenship and Immigration Services to verify the information provided and to conduct police,
welfare, and other record checks pertinent to this application.
Signature
Date (mm/dd/yyyy)
48. Signature of Person Preparing Form if Other Than Above (Sign below)
I declare that I prepared this application at the request of the above person(s), and it is based on all information provided to me by the
person(s). I have not knowingly withheld any material information that would affect the outcome of this application.
Attorney or Representative Only:
n the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
I
Yes
No
Preparer's Signature
Date (mm/dd/yyyy)
Print Preparer's Family Name (Last Name)
Print Preparer's Given Name (First Name)
Print Preparer's Middle Name
Preparer's Firm Name (if applicable)
Preparer's Address
Daytime Phone Number (with area code)
Fax Number (with area code)
USCIS Account Number (if any)
E-mail Address (if any)
Form I-687 06/20/17 Y Page 9

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