Form I-730 - Refugee/asylee Relative Petition - Department Of Homeland Security Page 7

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Part 8. Contact Information, Certification and Signature of the Person Preparing this Petition, if Other
Than the Petitioner or Beneficiary
Provide the following information about the preparer. If you filled out this petition yourself (without a preparer), please leave this
section blank.
Preparer's Full Name
1.a.
1.b.
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 + 4
-
Province
Postal Code
Country
Preparer's Contact Information
Preparer's Mobile Telephone Number (if any)
5.
4.
Preparer's Daytime Telephone Number
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, or Form G-28I, Notice of Entry of
Appearance as Attorney In Matters Outside the Geographical Confines of the United States, with this petition.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this petition at the request of the petitioner and/or the beneficiary.
The petitioner and beneficiary (if the beneficiary is in the United States and 14 years of age or older) then reviewed this completed
petition and informed me that he and/or she understands all of the information contained in, and submitted with, his and/or her
petition, including the Petitioner's Declaration and Certification, and the Beneficiary's Declaration and Certification that all of
this information is complete, true, and correct. I completed this petition based only on information that the petitioner and beneficiary
provided to me or authorized me to obtain or use.
Form I-730 (05/30/17) N Page 7

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