Form I-765v - Application For Employment Authorization For Abused Nonimmigrant Spouse Page 5
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6Part 6. Contact Information, Declaration, and
Preparer's Certification
Signature of the Person Preparing this
By my signature, I certify, under penalty of perjury, that I
Application, if Other Than the Applicant
prepared this application at the request of the applicant. The
(continued)
applicant then reviewed this completed application and
informed me that he or she understands all of the information
Preparer's Mailing Address
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
3.a.
Street Number
information is complete, true, and correct. I completed this
and Name
application based only on information that the applicant
3.b. Apt.
Ste.
Flr.
provided to me or authorized me to obtain or use.
3.c. City or Town
Preparer's Signature
3.d. State
3.e. ZIP Code
8.a. Preparer's Signature (sign in ink)
3.f.
Province
8.b. Date of Signature (mm/dd/yyyy)
3.g. Postal Code
3.h. Country
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)
Preparer's Statement
I am not an attorney or accredited representative
7.a.
but have prepared this application on behalf of
the applicant and with the applicant's consent.
I am an attorney or accredited representative and
7.b.
my representation of the applicant in this case
does not extend beyond the
extends
preparation of this application.
NOTE: If you are an attorney or accredited
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this application.
Form I-765V 01/19/17 N
Page 5 of 6
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