Form I-865 - Sponsor'S Notice Of Change Of Address Page 2
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4
51.b.
The interpreter named in Part 4. has also read to me
Part 2. Information About the Sponsored
every question and instruction on this notice, as well
Immigrants (continued)
as my answer to every question, in
Sponsored Immigrant 2
,
a language in which I am fluent. I understand every
3.a. Family Name
question and instruction on this notice as translated to
(Last Name)
me by my interpreter, and have provided complete,
3.b.
Given Name
true, and correct responses in the language indicated
(First Name)
above.
3.c.
Middle Name
2.
I have requested the services of and consented to
4.
A-Number (if any)
,
►
A-
who
is
is not an attorney or a accredited
representative, preparing this notice for me.
Sponsored Immigrant 3
Sponsor's Contact Information
5.a. Family Name
(Last Name)
Sponsor's Daytime Telephone Number
3.
5.b.
Given Name
(First Name)
5.c.
Middle Name
Sponsor's Mobile Telephone Number (if any)
4.
6.
A-Number (if any)
►
A-
5.
Sponsor's Email Address (if any)
Sponsored Immigrant 4
7.a. Family Name
Sponsor's Certification
(Last Name)
7.b.
Given Name
Copies of any documents I have submitted are exact
(First Name)
photocopies of unaltered, original documents, and I understand
that USCIS may require that I submit original documents to
7.c.
Middle Name
USCIS at a later date. Furthermore, I authorize the release of
any information from any and all of my records that USCIS
8.
A-Number (if any)
may need to determine my eligibility for the immigration
►
A-
benefit that I seek.
NOTE: If you are sponsoring more than four persons, use the
I furthermore authorize release of information contained in this
space provided in Part 6. Additional Information to provide
notice, in supporting documents, and in my USCIS records to
the information requested for each additional individual.
other entities and persons where necessary for the
administration and enforcement of U.S. immigration laws.
Part 3. Sponsor's Statement, Contact
I certify, under penalty of perjury, that the information in my
notice and any document submitted with my notice were
Information, Certification, and Signature
provided by me and are complete, true, and correct.
NOTE: Read the information on penalties in the Penalties
section of the Form I-865 Instructions before completing this
Sponsor's Signature
part.
6.a.
Sponsor's Signature
Sponsor's Statement
NOTE: Select the box for either Item Number 1.a. or 1.b. If
6.b.
Date of Signature (mm/dd/yyyy)
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and have read and
NOTE TO ALL SPONSORS: If you do not completely fill
understand every question and instruction on this
out this notice or fail to submit required documents listed in the
notice, as well as my answer to every question.
Instructions, USCIS may reject your notice.
Form I-865 07/17/15 N
Page 2 of 5
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