Form I-821 - Application For Temporary Protected Status Page 12
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13Part 9. Interpreter's Contact Information,
Preparer's Statement
Certification, and Signature (continued)
I am not an attorney or accredited representative but
7.a.
have prepared this application on behalf of the
Interpreter's Signature
applicant and with the applicant's consent.
7.a. Interpreter's Signature
I am an attorney or accredited representative and my
7.b.
representation of the applicant in this case
extends
does not extend beyond the
7.b. Date of Signature (mm/dd/yyyy)
preparation of this application.
NOTE: If you are an attorney or accredited representative
whose representation extends beyond preparation of this
Part 10. Contact Information, Declaration, and
application, you may be obliged to submit a completed Form
Signature of the Person Preparing this
G-28, Notice of Entry of Appearance as Attorney or Accredited
Application, if Other Than the Applicant
Representative, or G-28I, Notice of Entry of Appearance as
Attorney In Matters Outside the Geographical Confines of the
Provide the following information about the preparer.
United States with this application.
Preparer's Full Name
Preparer's Certification
1.a. Preparer's Family Name (Last Name)
By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and
1.b. Preparer's Given Name (First Name)
informed me that he or she understands all of the information
contained in, and submitted with, his or her application,
including the Applicant's Certification, and that all of this
2.
Preparer's Business or Organization Name (if any)
information is complete, true and correct. I completed this
application based only on information that the applicant
provided to me or authorized me to obtain or use.
Preparer's Mailing Address
Preparer's Signature
3.a. Street Number
and Name
8.a. Preparer's Signature
3.b.
Apt.
Ste.
Flr.
3.c. City or Town
8.b. Date of Signature (mm/dd/yyyy)
3.d. State
3.e. ZIP Code
3.f.
Province
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)
Form I-821 10/19/17 N
Page 12 of 13
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