Form Eoir-42b - Application For Cancellation Of Removal And Adjustment Of Status For Certain Nonpermanent Residents Page 12

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PART 7 - MISCELLANEOUS INFORMATION
(Continued)
J
J
63) Are you the beneficiary of an approved visa petition?
Yes
No
J
J
If yes, can you arrange a trip outside the United States to obtain an immigrant visa?
Yes
No If no, please explain:
64) The following certificates or other supporting documents are attached hereto as a part of this application: (Refer to the Instructions for
documents which should be attached.)
PART 8 - SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT
(Read the following information and sign below)
I declare that I have prepared this application at the request of the person named in Part 1, that the responses provided are based
on all information of which I have knowledge, or which was provided to me by the applicant, and that the completed applica-
tion was read to the applicant in a language the applicant speaks fluently for verification before he or she signed the applica-
tion in my presence. I am aware that the knowing placement of false information on the Form EOIR-42B may subject me to
civil penalties under 8 U.S.C. 1324c.
Signature of Preparer:
Print Name:
Date:
Address of Preparer: (Number and Street, City, State, Zip Code)
Daytime Telephone #:
(
)
Please continue answers on a separate sheet as needed.
Form EOIR-42B
Revised July 2014
(7)

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