Form I-824 - Application For Action On An Approved Application Or Petition Page 4
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7Part 3. Other Information (continued)
Applicant's Statement
26.a. Family Name
NOTE: Select the box for either Item Number 1.a. or 1.b.
(Last Name)
If applicable, select the box for Item Number 2.
26.b. Given Name
I can read and understand English, and have read and
1.a.
(First Name)
understand every question and instruction on this
26.c. Middle Name
application, as well as my answer to every question.
1.b.
The interpreter named in Part 5. has also read to me
27.
Date of Birth (mm/dd/yyyy)
every question and instruction on this application, as
28.
Country of Birth
well as my answer to every question, in
,
a language in which I am fluent. I understand every
29.
Country of Citizenship or Nationality
question and instruction on this application as
translated to me by my interpreter, and have provided
complete, true, and correct responses in the language
30.
Relationship to Principal Applicant
indicated above.
2.
I have requested the services of and consented to
31.
Dependent's Email Address (if any)
,
who
is
is not an attorney or accredited
representative, preparing this application for me.
32.
Dependent's Daytime Telephone Number
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
Foreign Address of Dependents
33.a. In Care Of Name
4.
Applicant's Mobile Telephone Number (if any)
33.b.
Street Number
and Name
Applicant's Email Address (if any)
5.
33.c.
Apt.
Ste.
Flr.
33.d.
City or Town
Applicant's Certification
33.e.
Province
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
33.f.
Postal Code
that USCIS may require that I submit original documents to
USCIS at a later date. Furthermore, I authorize the release of
33.g. Country
any information from any and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.
Contact Information of Dependents
I furthermore authorize release of information contained in this
application, in supporting documents, and in my USCIS records
34.
Foreign Telephone Number
to other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
I certify, under penalty of perjury, that the information in my
application and any document submitted with my application
Part 4. Applicant's Statement, Contact
were provided by me and are complete, true, and correct.
Information, Certification, and Signature
NOTE: Read the information on penalties in the Penalties
section of the Form I-824 Instructions before completing this
part.
Form I-824 12/23/16 N
Page 4 of 7
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