Form I-914 - Application For T Nonimmigrant Status Page 10
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10PART H. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Provide the following information about the preparer.
Preparer's Full Name
1. Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
2. Preparer's Business or Organization Name (if any)
Preparer's Mailing Address
3.
Street Number and Name
Apt.
Ste.
Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Telephone Number (if any)
6.
Preparer's Email Address (if any)
Preparer's Statement
7.
A.
I am not an attorney or accredited representative but have prepared this application on behalf of
the applicant and with the applicant's consent.
B.
I am an attorney or accredited representative and my 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, you may be obliged to submit a completed Form G-28,
Notice of Entry of Appearance as Attorney or Accredited Representative, with this application.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted with,
his or her application, including the Applicant's Declaration and Certification, and that all of this information is complete, true, and
correct. I completed this application based only on information that the applicant provided to me or authorized me to obtain or use.
Preparer's Signature
8.
Preparer's Signature (sign in ink)
Date of Signature (mm/dd/yyyy)
Page 10
Form I-914 02/27/17 Y
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