EFTA01684002.pdf

Attachment A CERTIFICATION FOR CONTINUED PRESENCE BY REQUESTING LAW ENFORCEMENT AGENCY TO: Unit Chief Parole and Law Enforcement Programs Unit Homeland Security Investigations U.S. Immigration and Customs Enforcement FROM: SAC FBI, New York Field Office RE: Request for Continued Presence fo SAC , of the FBI New York Field Office concur in this request and certify, in accordance with the Department of Homeland Security (DHS)'s procedures for Continued Presence, that: 1. The justification and information concerning the request for Continued Presence are accurate and complete. 2. Documentation is attached certifying that the alien is a victim of a severe form of trafficking and may be a potential witness to that trafficking. 3. Name checks have been completed in the principle law enforcement databases on the person named in the request (National Crime Information Center and any other databases available) and, as appropriate, information from foreign law enforcement agencies. Criminal history check results based on fingerprints have been received and any identification issues resolved. [For the FBI: Coordination has also been effected with appropriate member agencies of the Intelligence Community] 4. Copies of all database screens on the person named above, including negative responses, have been identified and forwarded to U.S. Immigration and Customs Enforcement, Homeland Security Investigations, Parole and Law Enforcement Programs Unit. 5. No promises have been made to the Victim that he or she will remain in the United States beyond the authorized period of Continued Presence. 6. An active investigation is underway by a law enforcement agency that requires the assistance of this subject. Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE EFTA01684002 Signature [of Authorizing Official] Date Printed Name [of Authorizing Official] Title [of Authorizing Official] Certification for Continued Presence by Requesting Law Enforcement Agency FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE EFTA01684003  DEPARTMENT OF HOMELAND SECURITY U.S. Immigration and Customs Enforcement REQUEST FOR CONTINUED PRESENCE Part A: Victkn 1. Name: (Last) (First) (Middle) 2. Date of Birth (mo., day, yr.) 3. Country of Birth 4. Country of Citizenship 02/21/1985 5. Alias(es) 6. Gender (check one) 7. Alien Number (A#) El Male ❑x Female A 8. Passport Number 9. Country of Issuance 10. Expiration Date (mo., day, yr.) 08/04/2020 s 05/14/2025 11. Social Security Number Part B: Requesting Agency Information 'Note: This information must be completed in order to receive consideration. 1. Lead Case Agent: 2. Daytime telephone number 3. Fax number (First, Last) (include area code) Ext. 2. Case Agent where the Victim resides (if the Victim resides in a jurisdiction other than that of the Lead Case Agent): (First, Last) 2. Daytime telephone number 3. Fax number (include area code) Ext. Supplemental Information: Requesting Agency: Federal Bureau of Investigation Group Supervisor's name (First, Last) Daytime telephone number (including area Co Fax number Victim-Witness Specialist's/Coordinators name (First, Lali fl Daytime telephone number (including area COCi fit. Fax number Request for Continued Presence FOR OFFICIAL USE ONLY I LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 1 of 4 EFTA01684004  Part 4:,case irifOr.Matiok, •Note: Please complete allInformation below. 1. Is the Victim currently in the United State 2. The Victim's current immigration status: 3. Is the Victim requesting Continued Presence based upon a pending civil action under 18 U.S.C. § 1595? ❑ yes ❑x No If yes, provide details of where and when the civil action was filed, and the status of the civil action. 4. Has the Victim ever been deported/presently under deportation proceedings? ❑ Yes ❑X No (if yes, where and when) City, State: 5. When did the Victim enter the United States? Ma 6. Through which Port of Entry did the Victim enter the United States? New York, New York 7. How did the Victim enter the United States? Flight Part D: Specific Information Pertaining to the Victim • Please answer each question as completely as possible (Attach additional sheet(s), it necessary.) 1. Significance and value of the Victim to this case: (Please provide a brief explanation of how the Victim meets the definition of 'severe form of trafficking' under section 103(8), Victims of Trafficking and Violence Protection Act of 2000, Pub. L No. 106-386.) See attached sheet. 2. The Victim's criminal Involvement in this or any other case: (Please attach or describe criminal and/or arrest record listing ALL criminal convictions.) No criminal convictions. 3. Risk the Victim presents to public safety and/or to national security (i.e., has the alien ever engaged in a terrorist act, supported terrorist activities, or is a member of a known terrorist group? If so, explain.) List and explain proposed security precautions if necessary: (Attach copy of risk assessment report) No risk to public safety or national security 4. Financial responsibility for the Victim: (Please explain manner in which the Victim's living expenses will be met) 5. Acquaintance/Relatives in the United States: (Please include name(s), relationship, and current location, i.e., city and state; attach additional sheet(s), if necessary.) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 2 of 4 EFTA01684005 6. Is employment authorization requested? El Yes ID No (If yes, please attach completed U.S. Citizenship and Immigration Services Forms 1-765, Application for Employment Authorization, and 1-102. Application for Replacement/Initial Nonimmigrant ArriveDeparture Document.) Note; Information contained in question #7 is not required for a victim to receive Continued Presence; however, this information is required for a victim to be certified to receive benefits from the Department of Health and Human Services (HHS), Office of Refugee Resettlement (ORR). A response to this question will assist HHS in ensuring the fast and efficient delivery of services to the Victim. Victims who have not attained 18 years of age do not need to be certified to receive benefits from HHS. 7. is the Victim willing to assist in every reasonable way in the investigation and prosecution of a severe form of trafficking in persons? The term "investigation and prosecution" includes the: 1) identification of a person or persons who have committed severe forms of trafficking in persons; * pprehension of such persons; and 3) testimony at proceedings against such persons. Part E: Location where the Victim will reside (City and State are required at a minimum.) Street Address City MM. State 'Initial requests are approved for a period of time determined on a case-by-case basis. ALL extensions for Continued Presence must be submitted to the ICE HSI Headquarters Law Enforcement Parole Unit (LEPU). Any change in status is to be reported to the requesting agency headquarters, which in turn will notify LEPU. The requesting agency will also notify LEPU immediately if the alien departs the United States. Part F: Certification of Reporting Requirements As the requesting agency representative, I understand that, should this Continued Presence be granted, it is MY responsibility to follow all of the policies and procedures established by LEPU, including quarterly reporting, reporting chap es in the Victim's status f.e. departure or change in status), and requesting applicable ex proved Continued Presence. 1 Atld 2020 (Date) If the Victim resides outside the geographic area of the lead Case Agent, a monitoring agent must be designated in the appropriate jurisdiction. (Monitoring Group Supervisor's Signature) (Print Name and Title) (Monitoring Case Agent's Signature) (Date) (Print Name and Title) Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Font 73-031 (4/11) Page 3 o, 4 EFTA01684006 Privacy Act Statement Authority: 22 U.S.C. §§ 7102(8) and 7105(c)(3) authorize ICE to collect the information requested on this form. Purpose(s): The information collected on this form will be used by ICE to: 1) clearly identify the individual for whom Continued Presence is being requested; 2) review and determine the eligibility of the individual to receive Continued Presence and remain in the United States; 3) grant or deny the request for Continued Presence; 4) identify and hold accountable the requesting law enforcement officer/agent and their agency to comply with ICE's policies and procedures for administering the Continued Presence; 5) coordinate the administration of benefits available to the individual (if eligible); and 6) properly maintain a record of all requests for Continued Presence as well as provide oversight, tracking and reporting on Continued Presence activity throughout the duration of the authorized Continued Presence. Routine Use(s): The information collected on this form may be shared with a criminal, civil, or regulatory law enforcement authority (whether Federal, State, local, territorial, tribal, international or foreign) where the information is necessary for collaboration, coordination and de-confliction of investigative matters. The information may also be disclosed as generally permitted under 5 U.S.C. § 552a(b) pursuant to the routine uses published in the Department of Homeland Security system of records notice, DHS/ICE-011 Immigration and Enforcement Operational Records. Disclosure: The disclosure of the information on this form is voluntary; however, failure to provide the information may result in the delay or ultimate denial of the request for Continued Presence. Request for Continued Presence FOR OFFICIAL USE ONLY / LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 4 of 4 EFTA01684007  FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE PART D:1 Jeffrey Epstein abused MIEver several years, beginning when she was 18 years old. It was during the course of this abuse that Epstein brought =Mao some of his massages to participate in sex acts with other girls. Epstein controlled every aspect of fe—including her physical appearance, her weight, and her clothing—for years. This controlling behavior took multiple abusive forms, including forcing o have multiple plastic surgeries, forcing her to engage in BDSM, referring to her as his "sex slave," insulting her, and physically abusing her, including by choking her and throwing her down a set of stairs. FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE EFTA01684008  Application for Replacement/Initial Nonimmigrant Arrival-Departure Document USCIS Form I-102 Department of Homeland Security OMB No. 1615-0079 U.S. Citizenship and Immigration Services Expires 10/31/2019 Receipt Action Block To Be Completed by an Attorney or Accredited Representative, if any. For 0 Select this box if Form USCIS G-28 is attached to Use New 1-94 Number represent the applicant. Only Attorney State License Number Remarks ar. START HERE. Type or print in black ink Part 1. Information About You U.S. Physical Address 1. Alien Registration Number (A-Number) 6.a. In Care Of Name ► A- ILII 2. USCIS Online Account Number pf 6.b. Street Number I I I 71 I] and Name 6.c. Apt. O Ste. 0 FIr. Your Full Name 6.d. City or Town 3.a. Family Name (Last Name) 6.e. State 6.1. ZIP Code 3.b. Given Name (First Name) Other Information 3.c. Middle Name 7. Date of Birth (mm/dd/yyyy) ► U.S Mailing Address 8. Co • 4.a. 9. oun of Citizenship 4.b. Street Number I'- and Name 10. .S. Social Security N 4.c. Apt. Ste. Entry Information 11. Date of Last Entry into the United 5. Is your cutrent U.S. mailing address (mm/dd/yyyy) ► U.S. physical address? 12. tes (Ci and State) If you answered "No" to Item Number 5., provide your U.S. physical address in Item Numbers 6.a. - 6.1. Form 1-102 10/19/17 N Page I of 4 EFTA01684009 Part 1. Information About You (continued) Part 3. Processing Information tatus 1.a. Arc you filing this application with any 13. IS Curren ' application? 0 14. Date Status Expires If "Yes" provide the USCIS Form Number and name of the (mm/dd/yyyy) ► application or petition you are filing in Item Number I.b. 1.b. USCIS Form Number and Name 15.a. Form I-94,1-94W, 2.a. Are you now in removal proceedings? lao 15.b. Passport Number If "Yes" complete Item Number 2.b. 15.c. Travel Document Number 2.b. Provide detailed information regarding the proceedings. 15.d. C Passport or Travel Document If you need extra space to complete any item, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet of paper; 15.e. Expiration Date for Passport or Travel Document indicate the Page Number, Part Number, and Item (mm/dd/yyyy) ► Number to which your answer refers; and date and sign I each sheet. Part 2. Reason for Application Select the box that best describes your reason for requesting an initial or replacement document. (Select only one box) If you are unable to provide the original of your Form 1-94, I -94W, or 1-95, provide the following information: NOTE: Provide your name exactly as it appears on Form 1-94, I -94W, or I-95. 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. Class of Admission at Last Entry into the United States E2 5. Place of Last En into the United States City and State) Form 1-102 10/19/17 N Page 2 of 4 EFTA01684010  Part 4. Statement, Certification, Signature, and Part 5. Contact Information, Certification, and Contact Information of the Applicant Signature of the Interpreter NOTE: Select the box for either Item Number 1.a. or 1.b. If Interpreter's Full Name applicable. select the box for Item Number 2. Provide the following information concerning the interpreter: 1.a. Interpreter's Family Name (Last Name) I.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Interpreter's Mailing Address 3.a. Street Number and Name 3.b. Apt. ❑ Ste. ❑ FIr. ❑ 3.c. City or Town 3.d. State 3.e. ZIP Code Applicant Certification 3.f. Province I certify, under penalty of perjury, that the foregoing is true and correct. Copies of documents submitted are exact 3.g. Postal Code photocopies of unaltered original documents, and I understand that I may be required to submit original 3.h. Country documents to U.S. Citizenship and Immigration Services (USCIS) at a later date. Furthermore, I authorize the release of any information from my records that USCIS may need to determine my eligibility for the benefit that I seek. I Interpreter's Contact Information furthermore authorize release of information contained in this 4. Interpreter's Daytime Telephone Number form, in supporting documents, and in my USCIS records, to other entities and persons where necessary for the administration of U.S. immigratio laws. 5. Interpreter's E-mail Address ature 3.b. Date of Signature (mm/dd/yyyy) ► Applicant's Contact Information 4. a Number 5. A limes Mobile Tel hone Number 6. A licant's E-mail Address Form I-102 10/19/17 N Page 3 of 4 EFTA01684011 Part 5. Contact Information, Certification, and Preparer's Contact Information Signature of the Interpreter (continued) 4. Preparer's Daytime Telephone Number Interpreter Certification I certify that: 5. Preparer's Fax Number I am fluent in English and ,which is the same language provided in Part 4., Item Number Lb.; 6. Preparer's E-mail Address I have read to this applicant every question and instruction on this form, as well as the answer to every question, in the language provided in Part 4., Item Number I.b.; and The applicant has informed me that he or she understands every instruction and question on the fonn, as well as the answer to every question. 6.a. Interpreter's Signature 6.b. Date of Signature (mm/dd/yyyy) ► r Preparer's Declaration By my signature, I certify, swear, or affirm, under penalty of Part 6. Contact Information, Declaration, and perjury, that I prepared this form on behalf of, at the request of, Signature of the Person Preparing this and with the express consent of the applicant. I completed the Application, If Other than the Applicant form based only on responses the applicant provided to me. After completing the form, I reviewed it and all of the Preparer's Full Name applicant's responses with the applicant, who agreed with every answer provided for every question on the form and, when Provide the following information concerning the preparer: required, supplied additional information to respond to a question on the form. l.a. Preparers Family Name (Last Name) 8.a. l.b. Name (First Name) 8.b. Date of Signature a r ddiyyyy) ► 2. Prill ' usiness or Organization Name NOTE: If you need extra space to provide any additional L information, attach a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet; indicate Preparer's Mailing Address the Page Number, Part Number, and Item Number to which your answer refers; and date and sign each sheet. 3.a. Street Number and Name 3.b. Apt. ❑ Ste. 3.c. City or Town 3.d. State 3.f. Province 3.g. Postal Code 3.6. Form 1402 10/19/17 N Page 4 of 4 EFTA01684012  Application For Employment Authorization USCIS Form 1-765 Department of Homeland Security OMB No. 1615-0040 U.S. Citizenship and Immigration Services Expires 05/31/2020 El Authorization/Extension Fee Stamp Action Block Valid From For ❑0 Authorization/Extension Valid Through USCIS Use Only Allen Registration Number A- i L I Remarks To be completed by an attorney or O Select this box if Form G-28 Attorney or Accredited Representative Board of Immigration Appeals (BIA)- is attached. USCIS Online Account Number (if any) accredited representative (if any). 10. START HERE - Type or print in black ink. Part 1. Reason for Applying Other Names Used I am applying for (select only one box): Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to 1.a. El Initial permission to accept employment. complete this section, use the space provided in Part 6. Lb. O Replacement of lost, stolen, or damaged employment Additional Informati authorization document, or correction of my 2.a. Family Name employment authorization document NOT DUE to (Last Name) U.S. Citizenship and Immigration Services (USCIS) 2.b. Given Name error. (First Name) NOTE: Replacement (correction) of an employment 2.c. Middle Name authorization document due to USCIS error does not require a new Form I-765 and filing fee. Refer to 3.a. Family Name Replacement for Card Error in the What is the (Last Name) Filing Fee section of the Form 1-765 Instructions for 3.b. Given Name further details. (First Name) Lc. 0 Renewal of my permission to accept employment. 3.c. Middle Name (Attach a copy of your previous employment authorization document.) 4.a. Family Name (Last Name) 4.b. Given Name Part 2. Information About You (First Name) 4.c. Middle Name Your Full Legal l.a. Family Name l.b. 1.c. Middle Name Form 1-765 12/26/19 Page 1 of 7 Nr4r1PROMINSMIRRNIVitellIll EFTA01684013 Part 2. Information About You (continued) 13.b. Provide your Social Securi Your U.S. Mailing Address 14. Do you want the SSA to issue you a Social Security card? (You must also answer "Yes" to Item Number 15., 5.a. In Care OfName (if any) Consent for Disclosure, to receive a card.) 0 Yes ®No 5.b. Street Number and Name NOTE: If you answered "No" to Item Number 14., skip to Part 2., Item Number 18.a. If you answered "Yes" to 5.c. Apt. ❑ Ste. Item Number 14., you must also answer "Yes" to Item Number 15. 5.d. City or Town 15. Consent for Disclosure: I authorize disclosure of 5.e. State ■ 51 ZIP Code information from this application to the SSA as required for the purpose of assigning me an SSN and issuing me a Social Security card. 0 Yes O No 6. Is your current mailing address the same as your h sical address? NOTE: If you answered "Yes" to Item Numbers 14. - 15., provide the information requested in Item NOTE: If you answered "No" to Item Number 6., Numbers 16.a. -17.b. provide your physical address below. Father's Name U.S. Physical Address Provide your father's birth name. 16.a. Family Name 7.a. Street Number (Last Name) and Name 16.b. Given Name 7.b. 0 Apt. 0 Ste. 0 FIr. (First Name) 7.c. City or Town Mother's Name Provide your mothers birth name. 7.d. State 7.e. ZIP Code 17.a. Family Name (Last Name) Other Information 17.b. Given Name (First Name) 8. Alien Registration Number (A-Number) (if any) I" A- Your Country or Countries of Citizenship or 9. USCIS Online Account Number (if any) Nationality ► List all countries where you are currently a citizen or national. If you need extra space to complete this item, use the space 10. Gender provided in Part 6. Additional Information. 11. Marital Status 18.a. IN Single 0 Married ❑ Divorced 0 Widowed 12. Have you previously filed Form I-765? 18.b. oun 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? 0 NOTE: If you answered "No" to Item Number 13.a., skip to Item Number 14. If you answered "Yes" to Item Number 13.a., provide the information requested in Item Number 13.b. Form 1-765 12/26/19 Page 2 of 7 EFTA01684014 Part 2. Information About You (continued) Information About Your Eligibility Category 27. Eligibility Category. Refer to the Who May File Form Place of Birth I-765 section of the Form I-765 Instructions to determine the appropriate eligibility category for this application. List the city/town/village, state/province, and country where Enter the appropriate letter and number for your eligibility you were born. category below (for example, (aX8). (cX17Xiii)). 19.a. Cit IfownNilla e of Birth 28. (eX3XC) STEM OPT Eligibility Category. If you 19.b. State/Province of Birth entered the eligibility category (cX3XC) in Item Number 27., provide the information requested in Item Numbers 28.a - 28.e. 19.e. Country of Birth 28.a. Degree 28.b. Employers Name as Listed in E-Verify 20. Date of Birth (mm/dd/yyyy) 28.c. Employer's E-Verify Company Identification Number or a Information About Your Last Arrival in the Valid E-Verify Client Company Identification Number United States 21.a. Form I-94 Arrival-Departure Record Number (if any) 29. (c)(26) Eligibility Category. If you entered the eligibility ► category (eX26) in Item Number 27., provide the receipt number of your H-1/1 spouse's most recent Form 1-797 21.b. P Most Recently Issued Passport Notice for Form 1-129, Petition for a Nonimmigrant Worker. 21.e. Travel Document Number (if any) ► 30. (c)(8) Eligibility Category. If you entered the eligibility category (cX8) in Item Number 27., have you EVER 21.d. Country That Issued Your Passport or Travel Document been arrested for and/or convicted of any crime? EI Yes ❑No 21.e. Expiration Date for Passport or T NOTE: If you answered "Yes" to Item Number 30., (mm/dd/yyyy) refer to Special Filing Instructions for Those With Pending Asylum Applications (c)(8) in the Required 22. Date of Your Last Arrival Into the ' Documentation section of the Form 1-765 Instructions About (mm/dd/yyyy) for information about providing court dispositions. 23. P Into the United States 31.a. (eX35) and (eX36) Eligibility Category. If you entered the eligibility category (cX35) in Item Number 27., please provide the receipt number of your Form 1-797 Notice for 24. Immigration Status at Your Last Arrival (for example, Form 1-140, Immigrant Petition for Alien Worker. If you B-2 visitor, F-1 student, or no status) entered the eligibility category (cX36) in Item Number E 27., please provide the receipt number of your spouse's or parent's Form 1-797 Notice for Form I-140. 25. Your Current Immigration Status or Category (for example, B-2 visitor, F-I student, parolee, deferred action, or no status or category) 31.b. If you entered the eligibility category (cX35) or (cX36) in Item Number 27., have you EVER been arrested for E and/or convicted of any crime? ❑ Yes ON° 26. Student and Exchange Visitor Information System (SEVIS) Number (if any) NOTE: If you answered "Yes" to Item Number 31.b., ► N- refer to Employment-Based Nonimmigrant Categories, Items 8. - 9., in the Who May File Form I-765 section of the Form 1-765 Instructions for information about providing court dispositions. Form 1-765 12/26/19 Page 3 of 7 EFTA01684015 Part 3. Applicant's Statement, Contact Applicant's Declaration and Certification Information, Declaration, Certification, and Copies of any documents I have submitted are exact photocopies Signature of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later NOTE: Read the Penalties section of the Form 1-765 date. Furthermore, I authorize the release of any information nstructions before completing this section. You must file from any and all ofmy records that USCIS may need to Form 1-765 while in the United States. determine my eligibility for the immigration benefit that I seek. Applicant's Statement I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS NOTE: Select the box for either Item Number 1.a. or I.b. If records, to other entities and persons where necessary for the applicable, select the box for Item Number 2. administration and enforcement of U.S. immigration law. 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 reviewed and understood all of the information contained in, and submitted with, my application; and 2) 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 application 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 application and that all of this information is complete, true, and Information I provided or authorized. correct. Applicant's Contact Information Applicant's Signal 3. Ap mber 4. 7.b. Date of Signature (mm/dd/yyyy) NOTE TO ALL APPLICANTS: If you do not completely fill 5. out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application. 6. 0 Select this box if you are a Salvadoran or Guatemalan national eligible for benefits under the ABC Part 4. Interpreter's Contact Information, settlement agreement. Certification, and Signature Provide the following information about the interpreter. Interpreter's Full Name 1.a. Interpreter's Family Name (Last Name) 1.b. Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) Page 4 of 7 Form 1.765 12126/19 INOrelatgairaTMEINTIMINIIIIII EFTA01684016 Part 4. Interpreter's Contact Information, Part 5. Contact Information, Declaration, and Certification, and Signature Signature of the Person Preparing this Application, If Other Than the Applicant Interpreter's Mailing Address Provide the following information about the preparer. 3.a. Street Number and Name Preparer's Full Name 3.b. O Apt. ❑ Ste. O Flr. l.a. Preparer's Family Name (Last Name) 3.c. City or Town I.b. Prepares Given Name (First Name) 3.d. State 3.e. ZIP Code 3.1. Province 2. arees Business or Organization Name (if any) 3.g. Postal Code 3.h. Country Preparer's Mullin Address 3.a. Street Number and Name Interpreter's Contact Information 3.b. O Apt. 0 Ste. Flr. 4. Interpreter's Daytime Telephone Number 3.c. City or Town 5. Interpreter's Mobile Telephone Number (if any) Id. State e. ZIP Code 3.1. Province 6. Interpreter's Email Address (if any) 3.g. Postal Code 3.h. Interpreter's Certification I certify, under penalty of perjury, that: Preparer's Contact Information I am fluent in English and which is the same language specified in Part 3., Item Number 4. Preparer's Daytime Telephone Number I.b., and I have read to this applican