Form I-854b - Inter-Agency Alien Witness And Informant Record Page 4
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4Part 2. Certifications (continued)
Office Name and Mailing Address
Office Name
Street Number and Name
Apt.
Ste.
Flr.
City or Town
State
ZIP Code
Office Contact Information
Daytime Telephone Number
Fax Number
E-mail Address
For U.S. Citizenship and Immigration Services Use Only
Adjustment Granted
Adjustment Denied
Date (mm/dd/yyyy)
Signature
Title
Name
Office Contact Mailing Information
Office Name
Street Number and Name
Apt.
Ste.
Flr.
City or Town
State
ZIP Code
Office Contact Information
Daytime Telephone Number
Fax Number
E-mail Address
Form I-854B 07/13/17 N
Page 4 of 4
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Parent category: Legal