Form I-817 - Application For Family Unity Benefits Page 11
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12Part 7. Contact Information, Statement,
Preparer's Statement
Certification, and Signature of the Person
I am not an attorney or accredited representative
7.a.
Preparing This Application, If Other Than the
but have prepared this application on behalf of the
Applicant
applicant and with the applicant's consent.
I am an attorney or accredited representative and
Provide the following information concerning the preparer.
7.b.
my representation of the applicant in this case
extends
does not extend beyond the
Preparer's Full Name
preparation of this application.
1.a. Preparer's Family Name (Last Name)
NOTE: If you are an attorney or accredited
representative whose representation extends
beyond preparation of this application you must
1.b. Preparer's Given Name (First Name)
submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited
Representative, with this application.
2.
Preparer's Business or Organization Name (if any)
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of
Preparer's Mailing Address
perjury, that I prepared this application on behalf of, at the
3.a.
Street Number
request of, and with the express consent of the applicant. I
and Name
completed this application based only on responses the
applicant provided to me. After completing the application, I
3.b.
Apt.
Ste.
Flr.
reviewed it and all of the applicant's responses with the
applicant, who agreed with every answer on the application.
3.c. City or Town
If the applicant supplied additional information concerning a
question on the application, I recorded it on the application. I
3.d. State
3.e. ZIP Code
have also read the Acknowledgement of Appointment at
USCIS Application Support Center to the applicant and the
3.f.
Province
applicant has informed me that he or she understands the ASC
Acknowledgement.
3.g.
Postal Code
3.h. Country
Preparer's Signature
8.a.
Preparer's Signature
Preparer's Contact Information
8.b. Date of Signature (mm/dd/yyyy)
4.
Preparer's Daytime Telephone Number
Part 8. Signature for Placement On Employment
5.
Preparer's Fax Number (if any)
Authorization Document
Provide your signature below. This signature will be scanned
6.
Preparer's Email Address (if any)
and duplicated for placement on your Employment Authorization
Document. When signing, make sure that no part of your
signature goes outside the lines of the box.
Signature
Form I-817 12/23/16 N
Page 11 of 12
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