EFTA00173740.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 for: 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 EFTA00173740 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 EFTA00173741  DEPARTMENT OF HOMELAND SECURITY U.S. Immigration and Customs Enforcement REQUEST FOR CONTINUED PRESENCE 'POPfliffoYminifion'ronttO\Vatitt 1. Name: (Last) (First) (Middle) 2. Date of Birth (mo., day, yr) 3. Country of Birth 4. Country of Citizenship 5. Alias(es) 6. Gender (check one) 7. Alien Number (A#) O Male ❑x Female A 8. Passport Number 9. Country of Issuance 10. Expiration Date (mo., day, yr.) 11. Social Security Number Part B: Requatinertgency 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 code) +1 ext. Fax number Victim-Witness Specialist's/Coordinator's name (First, Last) Daytime telephone number (including area code) + ext. Fax number Request for Continued Presence FOR OFFICIAL USE ONLY I LAW ENFORCEMENT SENSITIVE ICE Form 73-031 (4/11) Page 1 of 4 EFTA00173742  Part C: Case information *Note: Please complete allInformation below. 1. Is the Victim currently in the United States? D Yes 0 No 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? 0 Yes El 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? 0 Yes 0 No (if yes, where and when) City, State: 5. When did the Victim enter the United States? 6. Through which Port of Entry did the Victim enter the United States 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), if 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 (Le., 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 EFTA00173743 6. Is employment authorization requested? Yes n No (IIyes, please attach completed U.S. Citizenship and Immigration Services Forms 1-765, Application for Employment Authorization, and 1-102. Application for Replacement/Initial Nonimmigrant Arrival/Departure 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; 2) location and apprehension of such persons; and 3) testimony at proceedings against such persons. ill Yes ❑ No Part E: Location where the Victim will reside (City and state are required at a minimum.) Street Address City Nco, Y c}z 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. I 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 changes in the Victim's status (i.e., departure or change in status), and requesting applicable extens ved Continued Presence. Date) Title) 1 / I td2 020 (Lead C ature) (Date) (Print Name and Title) If the Victim resides outside the geographic area of the lead Case Agent, a monitoring agent must be designated in the appropriate jurisdiction. —1 I (Monitoring Group Supervisor's Signature) (Date) (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 Form 73-031 (4/11) Page 3 a' 4 EFTA00173744 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, DNS/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 (4111) Page 4 of 4 EFTA00173745  FOR OFFICIAL USE ONLY/ LAW ENFORCEMENT SENSITIVE PART D:1 Jeffrey Epstein abused over several years, beginning when she was 18 years old. It was during the course of this abuse that Epstein brought into some of his massages to participate in sex acts with other girls. Epstein controlled every aspect of s life—including her physical appearance, her weight, and her clothing—for years. This controlling behavior took multiple abusive forms, including forcing to 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 EFTA00173746  Application for Replacement/Initial Nonimmigrant Arrival-Departure Document USCIS Form 1-102 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 O-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 la. A- 2. USCIS Online Account Number if any) 6.b. Street Number and Name I II I ri l l 6.c. Apt. Ei Ste. 0 Fir. 0 Your Full Name 6.d. City or Town 3.a. Family Name (Last Name) 6.e. State 6.f. ZIP Code 3.b. Given Name (First Name) 3.c. Middle Name r Other Information 7. Date of Birth (mm/dd/yyyy) ► U.S Mailing Address 8. Count ofBirth 4.a. In Care Of Name 9. Count of 'fizen hi 4.b. Street Number and Name il 10. U.S. Social Security Number if an 4.c. Apt. 2 Ste. 0 Fir. 0 4.d. City or Town NEAN otkg Entry Information 4.e. State NY 4.1. ZIP Code 11. Date of Last Entry into the United States 5. Is your current U.S. mailing address the same as your (mm/dd/yyyy) ► U.S. physical address? 0 Yes 0 No 12. Place of Last Entry into the United States (City and State) If you answered "No" to Item Number 5., provide your U.S. physical address in Item Numbers 6.a. - 6.1. LDS -AN 66 LES CA- Form 1-102 10/19/17 N Page I of 4 EFTA00173747  Part 1. Information About You (continued) Part 3. Processing Information 13. Current Nonimmigrant Status l.a. Arc you filing this application with any other petition or application? O Yes gj No 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 1.b. 15.a. Form 1-94, I-94W, or 1-95 Arrival-D arture Record Number 1.b. USCIS Form Number and Name ► 15.b. Passport Number 2.a. Arc you now in removal proceedings? 0 Yes g No If "Yes" complete Item Number 2.b. 15.e. Travel Document Number 2.b. Provide detailed information regarding the proceedings. 154. Count of Issuance for Pass ort 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 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) l.a. O 1 am applying to replace my lost or stolen Form I-94 or I-94W. 1.b. O I am applying to replace my lost or stolen Form 1-95. 1.c. O I am applying to replace my Form 1-94 or I-94W because it was mutilated. I have attached my original Form 1-94 or I-94W. 1.d. 0 I am applying to replace my Form I-95 because it was If you are unable to provide the original of your Form 1-94, mutilated. I have attached my original Form 1-95. I -94W, or 1-95, provide the following information: 1.e. g I was not issued Form 1-94 when I was admitted by NOTE: Provide your name exactly as it appears on Form I-94, CBP at a port-of-entry in the United States (whether I -94W, or I-95. at a land border, airport, or seaport). 3.a. Family Name 11. O I was issued Form I-94,1-94W, or1-95 with incorrect (Last Name) information, and I am requesting that USCIS correct the 3.b. Given Name document. I have attached my original Form 1-94, (First Name) I-94W, or 1-95. 3.c. Middle Name 1.g. O I was not issued Form 1-94 when I entered as a 4. nonimmigrant member of the military, and I am filing this application for an initial Form 1-94. 5. Place ofLast Entry into the United States (City and State) LDS ANhEI-65 CA I\IG‘tv -PASS plepcitONI Form 1-102 10/19/17 N Page 2 of 4 EFTA00173748  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. 1.a. s] Ican read and understand English, and have read and Provide the following information concerning the interpreter: understand every question and instruction on this 1.a. Interpreter's Family Name (Last Name) form, as well as my answer to every question. l.b. ❑ The interpreter named below has read to me every question and instruction on this form, as well as my Lb. Interpreter's Given Name (First Name) answer to every question, in 2. Interpreter's Business or Organization Name (if any) a language in which I am fluent. I understand every question and instruction on this form as translated to me by my interpreter, and have provided true and correct responses in the language indicated Interpreter's Mailing Address above. 3.a. Street Number 2. ❑ I have requested the services of and consented to and Name 3.b. Apt. ID Ste. 0 FIr. O who is EI is not ❑ an attorney or accredited 3.c. City or Town representative, preparing this form for me. 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 form, in supporting documents, and in my USCIS records, to 4. Interpreter's Daytime Telephone Number other entities and persons where necessary for the administration of U.S. immi 5. Interpreter's E-mail Address ature 3.b. Date of Signature (mm/drYyyyy) ► --/N/24o Applicant's Contact Information 4. A licant's Da time Tel hone Number 5. A licant's Mobile Tele hone Number 6. A licant's E-mail Address Form I-102 10/19/17 N Page 3 of 4 EFTA00173749  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 1.6.; 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 7.a. xi I am not an attorney or accredited representative but have prepared this form on behalf of the applicant The applicant has informed me that he or she understands every and with the applicant's consent. instruction and question on the form, as well as the answer to every question. 7.b. ❑ I am an attorney or accredited representative and my representation of the applicant in this case 6.a. Interpreter's Signature (choose one) extends ❑ does not extend ❑ beyond the preparation of this form. 6.b. Date of Signature (mm/dd/yyyy) ► 1 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. I.a. Pre Carers Famil Name Last Name) 8.a. Lb. Pre ares Given Name First Name 8.b. Date of Signature d/yyyy) ► 2. Pre •arer's Business or Organization Namc NOTE: If you need extra space to provide any additional 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 2lo PED62AL PLAZA 3.b. Apt. ❑ Ste. Flr. ❑ It. City or Town NEW yotk Id. State Ntl 3.e. ZIP Code 10278 3.f. Province 3.g. Postal Code 3.b. Country UNIT-6Th SikreS Form 1-102 10/19/17 N Page 4 of 4 EFTA00173750  Application For Employment Authorization USCIS Form I-765 Department of Homeland Security OMB No. 1615-0040 U.S. Citizenship and Immigration Services Expires 05/31/2020 • Authorization/Extension Fee Stamp Action Block Valid From Authorization/Extension For ❑ Valid Through USCIS Use Only , Alien Registration Number A- Remarks To be completed by an attorney or ❑ 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). ► 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. ❑ Initial permission to accept employment. complete this section, use the space provided in Part 6. Lb. ❑ Replacement of lost, stolen, or damaged employment Additional Information. 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 1-765 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 I-765 Instructions for 3.b. Given Name further details. (First Name) 1.c. ❑ 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 Yon (First Name) 4.c. Middle Name Your Full Legal Name I.a. Family Name (Last Name) Lb. Given Name (First Name) ■ I.c. Middle Name Form 1-765 12/26/19 Page 1 of 7 EFTA00173751 Part 2. Information About You (continued) 13.6. Provide your Social Security number (SSN) (if known). Your U.S. Mai!keg 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 Of Name (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. 2 Apt. 0 Ste. 0 Flr. Item Number 14., you must also answer "Yes" to Item Number 15. 5.d. City or Town Nem Yock 15. Consent for Disclosure: I authorize disclosure of 5.e. State Ny 5.1. 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 0 No 6. Is your current mailing address the same as your physical address? VI Yes 0 No 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 mother's 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) ► 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 0 Male Ii Female provided in Part 6. Additional Information. 11. Marital Status 18.a. Country gs) Single 0 Married 0 Divorced ❑ Widowed 12. Have you previously filed Form I-765? 18.b. Country Oyes JNo 13.a. Has the Social Security Administration (SSA) ever officially issued a Social Security card to you? ®Yes 0 No 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. Page 2 of 7 Fenn 1-765 12126/19 VIII IMINVIMMVISINIMENAIMIIIII EFTA00173752 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), (c)(17Xiii)). 19.a. Ci /Town/Vill e of Birth ( )( )( 1 28. (cX3XC) 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.c. 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 1-94 Arrival-Departure Record Number (if any) 29. (c)(26) Eligibility Category. If you entered the eligibility category (cX26) in Item Number 27., provide the receipt number of your H-1B spouse's most recent Form 1-797 21.b. Pass oR Number of Your Most Recent) Issued Pass ort Notice for Form 1-129, Petition for a Nonimmigrant Worker. 21.c. Travel Document Number (if any) ► 30. (cX8) Eligibility Category. If you entered the eligibility category (cX8) in Item Number 27., have you EVER 21.d. Coun • That Issued Your Pass • •rt or Travel Document been arrested for and/or convicted of any crime? Ei Yes 0 No 21.e. Expiration Date for Passport or Travel Document NOTE: If you answered "Yes" to Item Number 30., (mm/dd/yyyy) refer to Special Filing Instructions for Those With Pending Asylum Applications (cX8) in the Required 22. Date of Your Last Arrival Into the United States, On or Documentation section of the Form 1-765 Instructions About (mm/dd/yyyy) for information about providing court dispositions. 23. Place of Your Last Arrival Into the United States 31.a. (eX35) and (eX36) Eligibility Category. If you entered the eligibility category (cX35) in Item Number 27., please LOS AMGELeS 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 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 cate o ) 31.b. If you ente ed the eligibility category (cX35) or (cX36) in Item Number 27., have you EVER been arrested for and/or convicted of any crime? 0 Yes 0 No 26. Student and Exchange Visitor Information System (SEWS) 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 I-765 12/26/19 Eltriseminivimmentginvomal14/ •HII Page 3 of 7 EFTA00173753  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 Instructions 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 La. or I.b. If records, to other entities and persons where neePcsary for the applicable, select the box for Item Number 2. administration and enforcement of U.S. immigration law. 1.a. .12;1 I can read and understand English, and I have read I understand that USCIS may require me to appear for an and understand every question and instruction on this appointment to take my biometrics (fingerprints, photograph, application and my answer to every question. 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.b. ❑ The interpreter named in Part 4. read to me every question and instruction on this application and my 1) I reviewed and understood all of the information answer to every question in contained in, and submitted with, my application; and 2) All of this information was complete, true, and correct a language in which I am fluent, and I understood at the time of filing. everything. I certify, under penalty of perjury, that all of the information in 2. El At my request, the preparer named in Part 5., 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 prepared this application for me based only upon application and that all of this information is complete, true, and information I provided or authorized. correct. Applicant's Contact Information Applicant's Signature 3. Applicant's Daytime Telephone Number 7.a. A licant's Si nature S 4. Applicant's Mobile Telephone Number (if any) 7.b. Date of Signature (mm/dd/yyyy) oi./I412620 NOTE TO ALL APPLICANTS: If you do not completely fill 5. A licant's Email Address (if any) out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application. 6. El 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