Form I-824 - Application For Action On An Approved Application Or Petition Page 6
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7Part 6. Contact Information, Statement,
Preparer's Certification
Certification, and Signature of the Person
By my signature, I certify, swear, or affirm, under penalty of
Preparing This Application, If Other Than the
perjury, that I prepared this application on behalf of, at the
Applicant (continued)
request of, and with the express consent of the applicant. I
completed this application based only on responses the
applicant provided to me. After completing the application, I
Preparer's Mailing Address
reviewed it and all of the applicant's responses with the
3.a.
Street Number
applicant, who agreed with every answer on the application. If
and Name
the applicant supplied additional information concerning a
question on the application, I recorded it on the application.
3.b.
Apt.
Ste.
Flr.
Preparer's Signature
3.c. City or Town
8.a.
Preparer's Signature
3.d. State
3.e. ZIP Code
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 Fax Number
6.
Preparer's Email Address (if any)
Preparer's Statement
I am not an attorney or accredited representative but
7.a.
have prepared this application on behalf of the
applicant and with the applicant's consent.
I am an attorney or accredited representative and my
7.b.
representation of the applicant in this case
extends
does not extend beyond the preparation of this
application.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this application, you must submit a
completed Form G-28, Notice of Entry of Appearance
as Attorney or Accredited Representative or G-28I,
Notice of Entry of Appearance as Attorney In Matters
Outside of the Geographical Confines of the United
States, with this application.
Form I-824 12/23/16 N
Page 6 of 7
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