Form I-817 - Application For Family Unity Benefits Page 10
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12Part 5. Applicant's Statement, Contact
Interpreter's Mailing Address
Information, Acknowledgement of Appointment
3.a.
Street Number
at USCIS Application Support Center,
and Name
Certification, and Signature (continued)
3.b.
Apt.
Ste.
Flr.
Applicant's Certification
3.c. City or Town
Copies of any documents I have submitted are exact photocopies
3.d. State
3.e. ZIP Code
of unaltered, original documents, and I understand that USCIS
may require that I submit original documents to USCIS at a later
3.f.
Province
date. Furthermore, I authorize the release of any information
from any and all of my records that USCIS may need to
3.g.
Postal Code
determine my eligibility for the immigration benefit that I seek.
I furthermore authorize release of information contained in this
3.h. Country
application, in supporting documents, and in my USCIS records
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
Interpreter's Contact Information
I certify, under penalty of perjury, that the information in my
application and any document submitted with my application
4.
Interpreter's Daytime Telephone Number
were provided by me and are complete, true, and correct.
5.
Interpreter's Email Address (if any)
Applicant's Signature
6.a.
Applicant's Signature
Interpreter's Certification
6.b. Date of Signature (mm/dd/yyyy)
I certify that:
NOTE TO ALL APPLICANTS: If you do not completely fill
I am fluent in English and
, which
out this application or fail to submit required documents listed
is the same language provided in Part 5., Item Number 1.b.;
in the Instructions, your application may be denied.
I have read to this applicant every question and instruction on
this application, as well as the answer to every question, in the
language provided in Part 5., Item Number 1.b.; and
Part 6. Interpreter's Contact Information,
Certification, and Signature
I have read the Acknowledgement of Appointment at USCIS
Application Support Center to the applicant in the same
Provide the following information concerning the interpreter.
language provided in Part 5., Item Number 1.b.
The applicant has informed me that he or she understands every
Interpreter's Full Name
instruction and question on the application, as well as the
answer to every question, and the applicant verified the
1.a. Interpreter's Family Name (Last Name)
accuracy of every answer; and
The applicant has also informed me that he or she understands
1.b. Interpreter's Given Name (First Name)
the ASC Acknowledgement and that by appearing for a USCIS
ASC biometric services appointment and providing his or her
fingerprints, photograph, and/or signature, he or she is
2.
Interpreter's Business or Organization Name (if any)
re-affirming that the contents of this application and all
supporting documentation are complete, true, and correct.
Interpreter's Signature
6.a.
Interpreter's Signature
6.b.
Date of Signature (mm/dd/yyyy)
Form I-817 12/23/16 N
Page 10 of 12
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