Petition for Amerasian, Widow(er), or Special Immigrant USCIS

Form I-360
Department of Homeland Security OMB No. 1615-0020
U.S. Citizenship and Immigration Services Expires 04/30/2020

For USCIS Use Only Fee Stamp Action Block

Returned
Resubmitted
Received
Relocated
Sent
Remarks: Petitioner/Applicant Classification
Interviewed
Interviewed Beneficiary
Interviewed
Consulate
I-485 Filed Concurrently
Bene "A" File Reviewed Priority Date

To be completed by an Select this box if Attorney State Bar Number Attorney or Accredited Representative
Attorney or Accredited Form G-28 or (if applicable) USCIS Online Account Number (if any)
Representative (if any). G-28I is attached.

► START HERE - Type or print in black ink.

Part 1. Information About Person or Organization Filing This Petition

NOTE: You must complete Part 1. as the petitioner if you are filing this petition on behalf of another person. If you are a Violence
Against Women Act (VAWA) self-petitioner or special immigrant juvenile, skip to Part 1., Item Number 7.

1. Your Full Name

Family Name (Last Name) Given Name (First Name) Middle Name

2. USCIS Online Account Number (if any) 3. U.S. Social Security Number (if any)
► ►

4. Alien Registration Number (A-Number) (if any) 5. Individual IRS Tax Number (if any)
► A- ►

6. Mailing Address (USPS ZIP Code Lookup)

In Care Of Name (if any)

Organization Name (if applicable)

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Form I-360 04/12/18 Page 1 of 19

Part 1. Information About Person or Organization Filing This Petition (continued)
7. Alternate and/or Safe Mailing Address
If you are a VAWA self-petitioning spouse, child, parent, or a special immigrant juvenile and do not want U.S. Citizenship and
Immigration Services (USCIS) to send notices about this petition to your home, you may provide an alternate and/or safe mailing
address.
In Care Of Name (if any)

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Part 2. Classification Requested

Select only one box.

1. A. Amerasian
B. Widow(er) of a U.S. citizen
C. Special Immigrant Juvenile
D. Special Immigrant Religious Worker

(1) Will the beneficiary be working as a minister? Yes No

E. Special Immigrant based on employment with the Panama Canal Company, Canal Zone Government, or U.S.
Government in the Canal Zone
F. Special Immigrant Physician
G. Special Immigrant G-4 International Organization Employee or Family Member or NATO-6 Employee or Family
Member
H. Special Immigrant Armed Forces Member
I. Self-Petitioning Spouse of Abusive U.S. citizen or Lawful Permanent Resident
J. Self-Petitioning Child of Abusive U.S. citizen or Lawful Permanent Resident
K. VAWA Self-Petitioning Parent of a U.S. citizen son or daughter
L. Special Immigrant Afghanistan or Iraq National who worked with the U.S. Armed Forces as a translator
M. Special Immigrant Iraq National who was employed by or on behalf of the U.S. Government
N. Special Immigrant Afghanistan National who was employed by or on behalf of the U.S. Government or the
International Security Assistance Force (ISAF) in Afghanistan
O. Broadcasters
P. Other
Provide the name of the classification below.

Form I-360 04/12/18 Page 2 of 19

Part 3. Information About the Person for Whom This Petition Is Being Filed
NOTE: On this petition, the "beneficiary" or "self-petitioner" means the person for whom this petition is being filed. If you provided
an alternate and/or safe mailing address above, you must also complete Part 3.

1. Your Full Name

Family Name (Last Name) Given Name (First Name) Middle Name

2. Mailing Address
In Care Of Name (if any)

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Other Information
3. Date of Birth (mm/dd/yyyy) 4. Country of Birth

5. U.S. Social Security Number (if any) 6. A-Number (if any)

► ► A-

7. Marital Status Single Married Divorced Widowed

Complete Item Numbers 8. - 15. if this person is in the United States. If an item number is not applicable or the answer is "none," leave
the space blank. Provide information below for the passport or other document used at the time of last arrival to the United States.
8. Date of Last Arrival (mm/dd/yyyy) 9. Form I-94 Number or I-95 Crewman's Landing Permit
►
10. Passport Number 11. Travel Document Number

12. Country of Issuance for Passport or Travel Document 13. Expiration Date for Passport or Travel Document
(mm/dd/yyyy)

14. Current Nonimmigrant Status 15. Date current status expired, or will expire, as shown on
Form I-94 or I-95 (mm/dd/yyyy)

Part 4. Processing Information

1. If the person listed in Part 3. is outside the U.S., is ineligible to adjust status in the U.S., or does not wish to adjust status in the
U.S., provide the following information about the U.S. Consulate at which the person prefers to apply for an immigrant visa.
U.S. Consulate
A. City or Town

B. Country

Form I-360 04/12/18 Page 3 of 19

Part 4. Processing Information (continued)
2. If a U.S. address was provided in Part 3., type or print the person's foreign address below. If he or she does not maintain a
foreign address, list the city or town and country of last foreign residence. If his or her native alphabet does not use Roman
letters, type or print his or her name and foreign address in the native alphabet.

A. Your Full Name

Family Name (Last Name) Given Name (First Name) Middle Name

B. Mailing Address
Street Number and Name Apt. Ste. Flr. Number

City or Town

Province Postal Code Country

3. Gender of the beneficiary: Male Female

4. A. Are you filing any other petitions or applications with this one? Yes No

B. If you answered "Yes" to Item A. in Item Number 4., how many?

If you answer "Yes" to Item Numbers 5. - 6., provide an explanation in the space provided in Part 15. Additional Information.

5. Is the beneficiary in removal proceedings? Yes No

6. Has the beneficiary ever worked in the U.S. without permission? (If you are applying for a special Yes No
immigrant juvenile status, you are not required to answer this item number.)

7. Is an application for adjustment of status attached to this petition? Yes No

Part 5. Information About the Spouse and Children of the Person for Whom This Petition Is Being Filed
NOTE: Depending on the classification you seek, you can either file this petition for another person or for yourself. On this petition,
the "beneficiary" or "self-petitioner" means the person for whom this petition is being filed, whether that person is yourself or another
person.

1. If you are filing as a self-petitioning spouse, have any of your children filed separate self-petitions? Yes No

2. Person 1
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Spouse Child ► A-

Form I-360 04/12/18 Page 4 of 19

Part 5. Information About the Spouse and Children of the Beneficiary (continued)
3. Person 2
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

4. Person 3
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

5. Person 4
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

6. Person 5
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

7. Person 6
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

Form I-360 04/12/18 Page 5 of 19

Part 5. Information About the Spouse and Children of the Beneficiary (continued)
8. Person 7
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

9. Person 8
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

10. Person 9
Family Name (Last Name) Given Name (First Name) Middle Name

Date of Birth (mm/dd/yyyy) Country of Birth

Relationship A-Number (if any)

Child ► A-

Part 6. Complete Only If Filing for an Amerasian

Information About the Mother of the Amerasian

1. Mother's Full Name
Family Name (Last Name) Given Name (First Name) Middle Name

2. A. Is the mother still alive? Unknown Yes No

B. If you answered "Yes" to Item A. in Item Number 2., provide her address below.
In Care Of Name (if any)

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Form I-360 04/12/18 Page 6 of 19

Part 6. Complete Only If Filing for an Amerasian (continued)
C. If you answered "No" to Item A. in Item Number 2., provide her date of death (mm/dd/yyyy).

Information About the Father of the Amerasian

If possible, attach a notarized statement from the father regarding parentage. If there is a question you cannot fully answer in the
space provided on this petition, use the space provided in Part 15. Additional Information.

3. Father's Full Name

Family Name (Last Name) Given Name (First Name) Middle Name

4. Date of Birth (mm/dd/yyyy) 5. Country of Birth

6. A. Is the father still alive? Unknown Yes No

B. If you answered "Yes" to Item A. in Item Number 6., provide his address below.
In Care Of Name (if any)

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

C. If you answered "No" to Item A. in Item Number 6., provide his date of death (mm/dd/yyyy).

D. Daytime Telephone Number (if any) E. Work Telephone Number (if any)

At the time the Amerasian was conceived:

7. A. The father was in the military (indicate branch of service below).

Army Air Force Navy Marine Corps Coast Guard

B. Provide the father's service number:

C. The father was not in the military and was not a civilian employed abroad. (Attach a full explanation of the
circumstances.)

Part 7. Complete Only If Filing as a Widow/Widower

1. Full Name of U.S. Citizen Husband or Wife Who Died
Family Name (Last Name) Given Name (First Name) Middle Name

2. Date of Birth (mm/dd/yyyy) 3. Country of Birth 4. Date of Death (mm/dd/yyyy)

Form I-360 04/12/18 Page 7 of 19

Part 7. Complete Only If Filing as a Widow/Widower (continued)
5. At time of death, your spouse was a (Select only one):
A. U.S. citizen born in the United States
B. U.S. citizen born abroad to U.S. citizen parents
C. U.S. citizen through naturalization

(1) Provide A-Number (if any) ► A-

D. Other (Explain)

6. How many times have you been married?

7. How many times was your spouse married?

8. A. When did you and your spouse get married (mm/dd/yyyy)?

B. Where did you and your spouse get married?

9. A. Did you remarry after the death of your spouse? Yes No

B. If you answered "Yes" to Item A. in Item Number 9., provide the date that you remarried (mm/dd/yyyy).

10. If you are filing as a widow(er), were you legally separated at the time of the U.S. citizen's death? Yes No

NOTE: If you answered "Yes" to Item Number 10., provide an explanation in the space provided in Part 15. Additional
Information.

Part 8. Complete Only If Filing for a Special Immigrant Juvenile

Information About the Juvenile

1. List any other names used:

A. Family Name (Last Name) Given Name (First Name) Middle Name

B. Family Name (Last Name) Given Name (First Name) Middle Name

Answer the following questions regarding the person for whom the petition is being filed. If you answer "No" to Item A. in Item
Number 2., provide an explanation in the space provided in Part 15. Additional Information.

2. A. Have you been declared dependent on a juvenile court in the United States OR has a juvenile court Yes No
legally committed you to, or placed you under the custody of, an agency, department of a state, or an
individual or entity?
B. Provide the name of the state agency, department, or court-appointed organization or individual with which you are placed
below.

C. Are you currently under the jurisdiction of the juvenile court that made your placement or custody Yes No
determination identified in Item B. in Item Number 2. above?

Form I-360 04/12/18 Page 8 of 19

Part 8. Complete Only If Filing for a Special Immigrant Juvenile (continued)
3. A. If you answered "Yes" to Item C. in Item Number 2. above, are you currently residing in your
Yes No
court-ordered placement?
B. If you answered "No" to Item C. in Item Number 2. above, select your reason below.
You were adopted or placed in a permanent guardianship or another permanent living arrangement (other than
reunification with the abusive parents).
You aged-out of the juvenile court's jurisdiction and the order was terminated based on age.
Other. (If you selected "Other," provide an explanation in the space provided in Part 15. Additional Information.)

4. A. A juvenile court has determined that reunification with one or both of my parents is not viable due to:

Abuse Neglect Abandonment

Similar basis under state law (specify):

B. If you selected "one" in Item A. in Item Number 4., provide the name of that parent below.

5. Has it been determined in judicial or administrative proceedings that it would not be in your best interest Yes No
to be returned to your or your parent's country of citizenship or nationality or last habitual residence?
6. A. Are you currently or were you previously in the custody of the U.S. Department of Health and Yes No
Human Services (HHS)?
B. If you answered "Yes" to Item A. in Item Number 6., and you are in HHS custody, did the juvenile Yes No
court order determine or alter your custody status or placement?

Part 9. Complete Only If Filing a Special Immigrant Religious Worker Petition

Prospective Employer Attestation

1. Provide the following information about the prospective employer.
A. Number of members of the prospective employer's organization

B. Number of employees working at the same location where the beneficiary will be employed

C. Number of aliens holding special immigrant or nonimmigrant religious worker status who are currently
employed or were employed within the past five years
D. Number of Special Immigrant Religious Worker (Form I-360) and Nonimmigrant Religious Worker
(Form I-129) petitions submitted by the prospective employer within the past five years
E. Number of Special Immigrant Religious Worker (Form I-360) petitions submitted by the beneficiary
during the last five years
2. Has the beneficiary or have any of the beneficiary's dependent family members previously been admitted Yes No
to the United States for a period of stay in the Religious Worker (R) classification during the last five
years?
If you answered "Yes" to Item Number 2., provide the beneficiary's and any dependent family member's prior periods of stay in
the R classification in the United States during the last five years. Be sure to provide only those periods when the beneficiary
and/or family members were actually in the United States in the R classification. Provide the beneficiary's information in Item
Number 3. below. For dependent family members, use the space provided in Part 15. Additional Information.
NOTE: Submit photocopies of Form I-94 Arrival-Departure Record, Form I-797 (Notice of Action), and/or other USCIS
documents identifying these periods of stay in the R classification. If you need extra space to complete this section, use the
space provided in Part 15. Additional Information.

Form I-360 04/12/18 Page 9 of 19

Part 9. Complete Only If Filing a Special Immigrant Religious Worker Petition (continued)
3. Beneficiary
Family Name (Last Name) Given Name (First Name) Middle Name

Period of Stay
From (mm/dd/yyyy) To (mm/dd/yyyy)

4. Provide a summary of the type of responsibilities of those employees, other than the beneficiary, who work at the same location
where the beneficiary will be employed. If you need extra space to complete this section, use the space provided in Part 15.
Additional Information.
Position

Summary of the Type of Responsibilities for That Position

5. Describe the relationship, if any, between the religious organization in the United States and the organization abroad of which
the beneficiary is a member.

6. Provide the following information about the prospective employment. If you need extra space to complete this section, use the
space provided in Part 15. Additional Information.
A. Title of position offered

B. The beneficiary will be working (select one of the following):

As a minister
In a religious vocation
In a religious occupation
C. Detailed description of the beneficiary's proposed daily duties

D. Description of the beneficiary's qualifications for the position offered

E. Description of the proposed salaried and/or non-salaried compensation

F. Provide the specific addresses or locations where the beneficiary will be working
Company Name

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Form I-360 04/12/18 Page 10 of 19

Part 9. Complete Only If Filing a Special Immigrant Religious Worker Petition (continued)
Answer Item Numbers 7. - 13. about the prospective employer. If you answer "No" for Item Numbers 7. - 13., provide an explanation
in the space provided in Part 15. Additional Information.

7. The prospective employer is a bona fide non-profit religious organization or a bona fide organization that Yes No
is affiliated with the religious denomination and is tax exempt as described in section 501(c)(3) of the
Internal Revenue Code of 1986, subsequent amendment, or equivalent sections of prior enactments of the
Internal Revenue Code. If the prospective employer is affiliated with the religious denomination,
complete the Religious Denomination Certification included in this petition.
If you answered "Yes," select the applicable box and attach the appropriate documentation to the petition.
A. A currently valid determination letter from the Internal Revenue Service (IRS) establishing that the organization is a
tax-exempt organization;
B. A currently valid determination letter from the IRS establishing that the organization is recognized as tax-exempt
under a group tax exemption; or
C. If you are claiming that the prospective employer is a bona fide organization that is affiliated with the religious
denomination, provide the following:
(1) A currently valid determination letter from the IRS establishing that the organization is a tax-exempt
organization;
(2) Documentation that establishes the religious nature and purpose of the organization, such as a copy of the
organizing instrument of the organization that specifies the purposes of the organization;
(3) Organizational literature, such as books, articles, brochures, calendars, flyers, and other literature describing
the religious purpose and nature of the activities of the organization; and
(4) A completed religious denomination certification, signed and dated, certifying that the petitioning
organization is affiliated with the religious denomination.
8. The prospective employer is willing and able to provide salaried and/or non-salaried compensation at a Yes No
level that the beneficiary and any dependents will not become a public charge.
9. The funds to pay the beneficiary's compensation do not include any monies obtained from the beneficiary, Yes No
excluding reasonable donations or tithing to the religious organization.
10. The beneficiary will not engage in secular employment, and the prospective employer will provide Yes No
salaried and/or non-salaried compensation.

11. The offered position is full time, requiring at least an average of 35 hours of work per week. Yes No

12. The beneficiary has been a religious worker for at least two years immediately before Form I-360 was Yes No
filed and is otherwise qualified for the position offered.
13. The beneficiary has been a member of the prospective employer's denomination for at least two years Yes No
immediately before Form I-360 was filed.

Prospective Employer Attestation (must be completed by the prospective employer even if the beneficiary is
filing on his or her own behalf)
I certify or attest under penalty of perjury under the laws of the United States of America that the contents of this attestation,
and the evidence submitted, are true and correct.
14. Signature of an Authorized Official of the Prospective Employer (sign in ink) Date of Signature (mm/dd/yyyy)

Form I-360 04/12/18 Page 11 of 19

Part 9. Complete Only If Filing a Special Immigrant Religious Worker Petition (continued)

Printed Name and Title of Signatory for Prospective Employer

15. Family Name (Last Name) Given Name (First Name) Middle Name

16. Title of the Signatory

Mailing Address
17. Employer/Organization Name

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Contact Information
18. Daytime Telephone Number 19. Fax Number (if any)

20. Email Address (if any)

Religious Denomination Certification (to be completed only if the prospective employer is affiliated with a
religious denomination)
I certify under penalty of perjury, that the prospective employer, ,

is affiliated with this Religious Denomination, , and that the attesting

religious organization within the religious denomination is tax-exempt as described in section 501(c)(3) of the Internal Revenue Code
of 1986, or equivalent sections of prior enactments of the Internal Revenue Code. The contents of this certification are true and
correct to the best of my knowledge.
21. Signature of the Authorized Representative of the Religious Denomination (sign in ink) Date of Signature (mm/dd/yyyy)

Printed Name and Title of the Signatory of the Religious Denomination

Given Name (First Name)
22. Family Name (Last Name) Middle Name

23. Title of the Signatory

Form I-360 04/12/18 Page 12 of 19

Part 9. Complete Only If Filing a Special Immigrant Religious Worker Petition (continued)

Information About the Attesting Religious Organization Within the Religious Denomination
24. Name of Attesting Religious Organization Within the Religious Denomination

25. Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

26. Daytime Telephone Number 27. Fax Number (if any)

28. Email Address (if any) 29. IRS Tax Number of the Attesting Religious Organization

Part 10. Complete Only If Filing as a VAWA Self-Petitioning Spouse or Child of a U.S. Citizen or
Lawful Permanent Resident or a VAWA Self-Petitioning Parent of a U.S. Citizen Son or Daughter
NOTE: For the safety and protection of all VAWA self-petitioners, information regarding a filing will only be provided to the
self-petitioner or their designated attorney or representative with a valid Form G-28, Notice of Entry of Appearance as
Attorney or Accredited Representative.

1. Full Name of U.S. citizen or Lawful Permanent Resident Abuser

Family Name (Last Name) Given Name (First Name) Middle Name

2. Date of Birth (mm/dd/yyyy) 3. Country of Birth 4. Date of Death (mm/dd/yyyy)

5. Your abuser is now, or was, a (Select one):

A. U.S. citizen born in the United States

B. U.S. citizen born abroad to U.S. citizen parents
C. U.S. citizen through naturalization

(1) Provide A-Number (if known) ► A-

D. U.S. Lawful Permanent Resident

(1) Provide A-Number (if any) ► A-

E. Other (Explain)

6. How many times have you been married? ►

7. How many times was your abuser married (if known)? ►

Form I-360 04/12/18 Page 13 of 19

Part 10. Complete Only If Filing as a VAWA Self-Petitioning Spouse or Child of a U.S. Citizen or
Lawful Permanent Resident or a VAWA Self-Petitioning Parent of a U.S. Citizen Son or Daughter
(continued)
8. A. When did you and your abuser get married? (If you are a self-petitioning child or self-petitioning parent, type or print "N/A.")
(mm/dd/yyyy)

B. Where did you and your abuser get married? (If you are a self-petitioning child or self-petitioning parent, type or print "N/A.")

9. When did you live with your abuser?

From (mm/dd/yyyy) To (mm/dd/yyyy)

Include any other dates you have lived off/on with your abuser in the space provided in Part 15. Additional Information.
10. Provide the last address at which you lived together with your abuser.
Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

11. Provide the last date that you lived together with your abuser at this address.
From (mm/dd/yyyy) To (mm/dd/yyyy)

12. I am currently residing in the United States and I request an Employment Authorization Document. Yes No

Part 11. Petitioner's Statement, Contact Information, Declaration, and Signature (Individual)
IMPORTANT: Complete this section ONLY if you are an individual filing this petition for yourself. If you are filing Form I-360 to
petition for another person or as an authorized signatory of an organization, complete Part 12. Statement, Contact Information,
Declaration, and Signature of the Petitioner or Authorized Signatory.
NOTE: Read the Penalties section of the Form I-360 Instructions before completing this part.

Petitioner's Statement
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

1. Petitioner's Statement Regarding the Interpreter

A. I can read and understand English, and I have read and understand every question and instruction on this petition and
my answer to every question.
B. The interpreter named in Part 13. read to me every question and instruction on this petition and my answer to every
question in ,
a language in which I am fluent. I understand all of this information as interpreted.

2. Petitioner's Statement Regarding the Preparer

At my request, the preparer named in Part 14., ,
prepared this petition for me based only upon information I provided or authorized.

Form I-360 04/12/18 Page 14 of 19

Part 11. Petitioner's Statement, Contact Information, Declaration, and Signature (Individual) (continued)

Petitioner's Contact Information

3. Petitioner's Daytime Telephone Number 4. Petitioner's Mobile Telephone Number (if any)

5. Petitioner's Email Address (if any)

Petitioner's Declaration and Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this petition, in supporting documents, and in my USCIS records to other
entities and persons where necessary for the administration and enforcement of U.S. immigration laws.

I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I provided or authorized all of the information contained in, and submitted with, my petition;
2) I reviewed and understood all of the information in, and submitted with, my petition; and
3) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury, that all of the information in my petition and any document submitted with it were provided or
authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my petition, and that all of
this information is complete, true, and correct.

Petitioner's Signature
6. Petitioner's Signature Date of Signature (mm/dd/yyyy)

NOTE TO ALL PETITIONERS: If you do not completely fill out this petition or fail to submit required documents listed in the
Instructions, USCIS may deny your petition.

Part 12. Statement, Contact Information, Declaration, and Signature of the Petitioner or Authorized
Signatory
IMPORTANT: Complete this section ONLY if you are filing Form I-360 to petition for another person or as an authorized signatory
of an organization. If you are an individual filing this petition for yourself, complete Part 11. Petitioner's Statement, Contact
Information, Declaration, and Signature (Individual).
NOTE: Read the Penalties section of the Form I-360 Instructions before completing this part.

Petitioner's or Authorized Signatory's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

1. Petitioner's Statement Regarding the Interpreter

A. I can read and understand English, and I have read and understand every question and instruction on this petition and
my answer to every question.

Form I-360 04/12/18 Page 15 of 19

Part 12. Statement, Contact Information, Declaration, and Signature of the Petitioner or Authorized
Signatory (continued)
B. The interpreter named in Part 13. read to me every question and instruction on this petition and my answer to every
question in ,
a language in which I am fluent. I understand all of this information as interpreted.

2. Petitioner's Statement Regarding the Preparer

At my request, the preparer named in Part 14., ,
prepared this petition for me based only upon information I provided or authorized.

Authorized Signatory's Contact Information

3. Authorized Signatory's Family Name (Last Name) Authorized Signatory's Given Name (First Name)

4. Authorized Signatory's Title 5. Authorized Signatory's Daytime Telephone Number

6. Authorized Signatory's Mobile Telephone Number (if any) 7. Authorized Signatory's Email Address (if any)

Petitioner's or Authorized Signatory's Declaration and Certification

Copies of any documents submitted are exact photocopies of unaltered, original documents, and I understand that, as the petitioner, I
may be required to submit original documents to USCIS at a later date.
I authorize the release of any information from my records, or from the petitioning organization's records, to USCIS or other entities
and persons where necessary to determine eligibility for the immigration benefit sought or where authorized by law. I recognize the
authority of USCIS to conduct audits of this petition using publicly available open source information. I also recognize that any
supporting evidence submitted in support of this petition may be verified by USCIS through any means determined appropriate by
USCIS, including but not limited to, on-site compliance reviews.

If filing this petition on behalf of an organization, I certify that I am authorized to do so by the organization.
I certify, under penalty of perjury, that I have reviewed this petition, I understand all of the information contained in, and submitted
with, my petition, and all of this information is complete, true, and correct.

Petitioner's or Authorized Signatory's Signature

8. Petitioner's or Authorized Signatory's Signature Date of Signature (mm/dd/yyyy)

NOTE TO ALL PETITIONERS AND AUTHORIZED SIGNATORIES: If you do not completely fill out this petition or fail to
submit required documents listed in the Instructions, USCIS may delay a decision on or deny your petition.

Form I-360 04/12/18 Page 16 of 19

Part 13. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

Interpreter's Full Name

1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name)

2. Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

3. Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number 5. Interpreter's Mobile Telephone Number (if any)

6. Interpreter's Email Address (if any)

Interpreter's Certification
I certify, under penalty of perjury, that:

I am fluent in English and , which is the same language specified in Part 11., Item B. in
Item Number 1., or in Part 12., Item B. in Item Number 1., and I have read to this petitioner or the authorized signatory in the
identified language every question and instruction on this petition and his or her answer to every question. The petitioner or
authorized signatory informed me that he or she understands every instruction, question, and answer on the petition, including the
Petitioner's Declaration and Certification, or Petitioner's or Authorized Signatory's Declaration and Certification, and has
verified the accuracy of every answer.

Interpreter's Signature
7. Interpreter's Signature (sign in ink) Date of Signature (mm/dd/yyyy)

Form I-360 04/12/18 Page 17 of 19

Part 14. Contact Information, Declaration, and Signature of the Person Preparing this Petition, if Other
Than the Petitioner
Provide the following information about the preparer.

Preparer's Full Name

1. 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

Province Postal Code Country

Preparer's Contact Information

4. Preparer's Daytime Telephone Number 5. Preparer's Mobile 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 petition on behalf of the
petitioner and with the petitioner's consent.
B. I am an attorney or accredited representative and my representation of the petitioner in this case
extends does not extend beyond the preparation of this petition.

NOTE: If you are an attorney or accredited representative whose representation extends beyond
preparation of this petition, you may be obliged to submit a completed Form G-28, Notice of Entry
of Appearance as Attorney or Accredited Representative, or 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 or authorized signatory.
The petitioner has reviewed this completed petition, including the Petitioner's Declaration and Certification, or Petitioner's or
Authorized Signatory's Declaration and Certification, and informed me that all of this information in the form and in the
supporting documents is complete, true, and correct.

Preparer's Signature
8. Preparer's Signature (sign in ink) Date of Signature (mm/dd/yyyy)

Form I-360 04/12/18 Page 18 of 19

 Part 15. Additional Information
If you need extra space to provide any additional information within this petition, use the space below. If you need more space than
what is provided, you may make copies of this page to complete and file with this petition or attach a separate sheet of paper. Type or
print 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.
1. Family Name (Last Name) Given Name (First Name) Middle Name

2. A-Number (if any) ► A-

3. A. Page Number B. Part Number C. Item Number

D.

4. A. Page Number B. Part Number C. Item Number

D.

5. A. Page Number B. Part Number C. Item Number

D.

6. A. Page Number B. Part Number C. Item Number

D.

Form I-360 04/12/18 Page 19 of 19