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Part 5. Applicant’s Statement, Contact Information, Acknowledgement of Appointment at USCIS Application

Support Center, Certification, and Signature

Item Numbers 1.a. - 6.b. Select the appropriate box to indicate that you either read this application yourself or someone

interpreted this application for you from English to a language in which you are fluent. If applicable, select the box to

indicate if someone prepared this application for you. You must also affirm that you have read and understand (or that an

interpreter or preparer read to you and you understand) the Acknowledgement of Appointment at USCIS Application

Support Center in Part 5. Further, you must sign and date your application and provide your daytime telephone

number, mobile telephone number (if any), and email address (if any). Every application MUST contain the signature

of the applicant (or parent or legal guardian, if applicable). A stamped or typewritten name in place of a signature is not

acceptable.

Part 6. Interpreter’s Contact Information, Certification, and Signature

Item Numbers 1.a. - 6.b. If you used anyone as an interpreter to read the instructions and questions on this application to

you in a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and

address of his or her business or organization (if any), his or her daytime telephone number, and his or her email address

(if any). The interpreter must also certify that he or she has read the Acknowledgement of Appointment at USCIS

Application Support Center in Part 5. to you in the same language in which you are fluent. The interpreter must sign

and date the application.

Part 7. Contact Information, Statement, Certification, and Signature of the Person Preparing this Application, If

Other Than the Applicant

Item Numbers 1.a. - 8.b. This section must contain the signature of the person who completed your application, if other

than you, the applicant. If the same individual acted as your interpreter and your preparer, that person should complete

both Part 6. and Part 7. If the person who completed this application is associated with a business or organization, that

person should complete the business or organization name and address information. Anyone who helped you prepare this

application MUST sign and date the application. A stamped or typewritten name in place of a signature is not acceptable.

Anyone who helped you prepare your application must also certify that he or she has read the Acknowledgement

of Appointment at USCIS Application Support Center in Part 5. to you, and that you informed him or her that

you understood the ASC Acknowledgement. If the person who helped you prepare your application is an attorney

or accredited representative, he or she must also submit a completed Form G-28, Notice of Entry of Appearance as

Attorney or Accredited Representative, or Form G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the

Geographical Confines of the United States, along with your application.

Part 8. Additional Information

Item Numbers 1.a. - 8.b. If you need extra space to provide any additional information within this application, use the

space provided in Part 8. Additional Information. If you need more space than what is provided in Part 8., you may

make copies of Part 8. to complete and file with this application or attach a separate sheet of paper. Include your name

and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which

your answer refers; and sign and date each sheet.

We recommend that you print or save a copy of your completed application to review in the future and

for your records. We recommend that you review your copy of your completed application before you

come to your biometric services appointment at a USCIS ASC. At your appointment, USCIS will permit

you to complete the application process only if you are able to confirm, under penalty of perjury, that all of the

information in your application is complete, true, and correct. If you are not able to make that attestation in good

faith at that time, USCIS will require you to return for another appointment.

Form I-212 Instructions 12/23/16 N

Page 12 of 18

Instructions For Form I-212 - Application For Permission To Reapply For Admission Into The United States After Deportation Or Removal Page 12