Fillable Form I-865 - Sponsor'S Notice Of Change Of Address (Page 4 of 5) in pdf

Form I-865 - Sponsor'S Notice Of Change Of Address Page 4

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Part 5. Contact Information, Statement,

Certification, and Signature of the Person

Preparing this Notice, If Other Than the Sponsor

(continued)

Preparer's Statement

I am not an attorney or accredited representative

7.a.

but have prepared this notice on behalf of the

sponsor and with the sponsor's consent.

I am an attorney or accredited representative and

7.b.

my representation of the sponsor in this case

extends

does not extend beyond the

preparation of this notice.

NOTE: If you are an attorney or accredited

representative whose representation extends

beyond preparation of this notice, you must

submit a completed Form G-28, Notice of Entry

of Appearance as Attorney or Accredited

Representative, with this notice.

Preparer's Certification

By my signature, I certify, swear, or affirm, under penalty of

perjury, that I prepared this notice on behalf of, at the request

of, and with the express consent of the sponsor. I completed

this notice based only on responses the sponsor provided to me.

After completing the notice, I reviewed it and all of the

sponsor's responses with the sponsor, who agreed with every

answer on the notice. If the sponsor supplied additional

information concerning a question on the notice, I recorded it on

the notice.

Preparer's Signature

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Form I-865 07/17/15 N

Page 4 of 5

Form I-865 - Sponsor'S Notice Of Change Of Address Page 4

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