Preparer's Certification
Part 8. Contact Information, Statement,
Certification, and Signature of the Person
By my signature, I certify, swear, or affirm, under penalty of
Preparing this Contract, If Other Than the
perjury, that I prepared this contract on behalf of, at the request
of, and with the express consent of the household member and
Household Member (continued)
sponsor. I completed this contract based only on responses the
household member and sponsor provided to me. After
Preparer's Mailing Address
completing the contract, I reviewed it and all of the household
3.a.
Street Number
member's and sponsor's responses with the household member
and Name
and sponsor, who agreed with every answer on the contract. If
the household member or sponsor supplied additional
3.b.
Apt.
Ste.
Flr.
information concerning a question on the contract, I recorded it
on the contract.
3.c. City or Town
Preparer's Signature
3.d. State
3.e. ZIP Code
8.a. Preparer's Signature
3.f.
Province
3.g.
Postal Code
8.b. Date of Signature (mm/dd/yyyy)
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 contract on behalf of the
household member and sponsor, and with the
household member and sponsor's consent.
I am an attorney or accredited representative and my
7.b.
representation of the household member and sponsor
in this case
extends
does not extend beyond
the preparation of this contract.
NOTE: If you are an attorney or accredited
representative whose representation extends beyond
preparation of this contract, you must submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Representative, with this contract.
Form I-864A 07/02/15 N
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