Form I-865 - Sponsor'S Notice Of Change Of Address Page 5
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5Part 3. Sponsor's Signature
(Read the information on penalties in the instructions before completing this part)
I certify, under penalty of perjury under the laws of the United States of America, that all the information provided on this notice is
true and correct.
Signature
Date (mm/dd/yyyy)
Part 4. Signature of Person Preparing Form, If Other Than Above
(Sign below)
I declare that I prepared this request at the request of the above person, and it is based on all information of which I have knowledge.
Preparer's Signature
Preparer's Printed Name
Date (mm/dd/yyyy)
Preparer's Firm Name (if applicable)
Preparer's Address
Daytime Phone Number (with area code)
Fax Number (if any)
E-Mail Address (if any)
Form I-865 (Rev. 10/26/10)Y Page 2
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