Form I 129, also known as the Petition for Alien Worker, is a document used to request permission from USCIS to employ a foreign national in the United States. The form is used by employers who want to hire an alien for full-time or temporary employment in the United States. In order to complete Form I 129, you will need specific information about the foreign national you are hiring, including their passport information and visa classification. There are a number of supporting documents that must be included with your petition, so it is important to review all requirements before submitting your application. Failure to include all required documentation could lead to delays or even a denial of your petition.
The listing features information regarding the form i 129. It is a good idea that you check out this information before you decide to begin working with the PDF.
Question | Answer |
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Form Name | Form I 129 |
Form Length | 42 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 10 min 30 sec |
Other names |
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Petition for a Nonimmigrant Worker |
USCIS |
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Department of Homeland Security |
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OMB No. |
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U.S. Citizenship and Immigration Services |
Expires 10/31/2021 |
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Receipt |
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Partial Approval (explain) |
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Action Block |
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USCIS |
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Class: |
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Classification Approved |
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No. of Workers: |
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Consulate/POE/PFI Notified |
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Job Code: |
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At: |
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Validity Dates: |
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Extension Granted |
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From: |
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COS/Extension Granted |
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►START HERE - Type or print in black ink.
Part 1. Petitioner Information
If you are an individual filing this petition, complete Item Number 1. If you are a company or an organization filing this petition, complete Item Number 2.
1.Legal Name of Individual Petitioner
Family Name (Last Name) |
Given Name (First Name) |
Middle Name |
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2.Company or Organization Name
3.Mailing Address of Individual, Company or Organization In Care Of Name
Street Number and Name |
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Apt. Ste. Flr. |
Number |
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City or Town |
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State |
ZIP Code |
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Province |
Postal Code |
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4.Contact Information
Daytime Telephone Number |
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Mobile Telephone Number |
Email Address (if any) |
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5.Other Information
Federal Employer Identification Number (FEIN)
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Individual IRS Tax Number
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U.S. Social Security Number (if any)
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Form |
Page 1 of 42 |
Part 2. Information About This Petition (See instructions for fee information)
1. Requested Nonimmigrant Classification (Write classification symbol):
2.Basis for Classification (select only one box):
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a. |
New employment. |
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b. |
Continuation of previously approved employment without change with the same employer. |
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c. |
Change in previously approved employment. |
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d. |
New concurrent employment. |
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e. |
Change of employer. |
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f. |
Amended petition. |
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3. |
Provide the most recent petition/application receipt number for the |
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beneficiary. If none exists, indicate "None." |
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4. |
Requested Action (select only one box): |
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a. Notify the office in Part 4. so each beneficiary can obtain a visa or be admitted. (NOTE: A petition is not required for
b. Change the status and extend the stay of each beneficiary because the beneficiary(ies) is/are now in the United States in another status (see instructions for limitations). This is available only when you check "New Employment" in Item Number 2., above.
c. Extend the stay of each beneficiary because the beneficiary(ies) now hold(s) this status.
d. Amend the stay of each beneficiary because the beneficiary(ies) now hold(s) this status.
e. Extend the status of a nonimmigrant classification based on a free trade agreement. (See Trade Agreement Supplement to Form
f. Change status to a nonimmigrant classification based on a free trade agreement. (See Trade Agreement Supplement to Form
5. Total number of workers included in this petition. (See instructions relating to |
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when more than one worker can be included.) |
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Part 3. Beneficiary Information (Information about the beneficiary/beneficiaries you are filing for. Complete the blocks below. Use the
1.If an Entertainment Group, Provide the Group Name
2.Provide Name of Beneficiary
Family Name (Last Name) |
Given Name (First Name) |
Middle Name |
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3.Provide all other names the beneficiary has used. Include nicknames, aliases, maiden name, and names from all previous marriages.
Family Name (Last Name) |
Given Name (First Name) |
Middle Name |
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4. |
Other Information |
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Date of birth (mm/dd/yyyy) |
Gender |
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U.S. Social Security Number (if any) |
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Male |
Female |
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Form |
Page 2 of 42 |
Part 3. Beneficiary Information (Information about the beneficiary/beneficiaries you are filing for. Complete the blocks below. Use the
Alien Registration Number
►A-
Province of Birth |
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Country of Citizenship or Nationality |
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5.If the beneficiary is in the United States, complete the following:
Date of Last Arrival (mm/dd/yyyy) |
Passport or Travel Document Number |
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Date Passport or Travel Document Issued (mm/dd/yyyy)
Date Passport or Travel Document Expires (mm/dd/yyyy)
Passport or Travel Document Country of Issuance
Current Nonimmigrant Status |
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Date Status Expires or D/S (mm/dd/yyyy) |
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Student and Exchange Visitor Information System (SEVIS) |
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Employment Authorization Document (EAD) |
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Number (if any) |
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Number (if any) |
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6.Current Residential U.S. Address (if applicable) (do not list a P.O. Box)
Street Number and Name |
Apt. Ste. Flr. |
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City or Town |
State |
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ZIP Code |
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Part 4. Processing Information
1.If a beneficiary or beneficiaries named in Part 3. is/are outside the United States, or a requested extension of stay or change of status cannot be granted, state the U.S. Consulate or inspection facility you want notified if this petition is approved.
a.Type of Office (select only one box):
b.Office Address (City)
Consulate
Port of Entry |
c. U.S. State or Foreign Country
d. Beneficiary's Foreign Address |
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Street Number and Name |
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Apt.Ste. Flr. Number |
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City or Town |
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State |
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Province |
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2.Does each person in this petition have a valid passport?
Yes
No. If no, go to Part 10. and type or print your explanation.
Form |
Page 3 of 42 |
Part 4. Processing Information (continued)
3.Are you filing any other petitions with this one?
Yes. If yes, how many? ►
No
4.Are you filing any applications for replacement/initial
Yes. If yes, how many? ►
5.Are you filing any applications for dependents with this petition?
Yes. If yes, how many? ►
6.Is any beneficiary in this petition in removal proceedings?
Yes. If yes, proceed to Part 10. and list the beneficiary's(ies) name(s).
7.Have you ever filed an immigrant petition for any beneficiary in this petition?
Yes. If yes, how many? ►
8.Did you indicate you were filing a new petition in Part 2.?
Yes. If yes, answer the questions below.
No
No
No
No
No. If no, proceed to Item Number 9.
a.Has any beneficiary in this petition ever been given the classification you are now requesting within the last seven years?
Yes. If yes, proceed to Part 10. and type or print your explanation.
No
b.Has any beneficiary in this petition ever been denied the classification you are now requesting within the last seven years?
Yes. If yes, proceed to Part 10. and type or print your explanation.
9.Have you ever previously filed a nonimmigrant petition for this beneficiary?
No
Yes. If yes, proceed to Part 10. and type or print your explanation.
No
10.If you are filing for an entertainment group, has any beneficiary in this petition not been with the group for at least one year?
Yes. If yes, proceed to Part 10. and type or print your explanation.
No
11.a. Has any beneficiary in this petition ever been a
Yes. If yes, proceed to Item Number 11.b.
No
11.b. If you checked yes in Item Number 11.a., provide the dates the beneficiary maintained status as a
Part 5. Basic Information About the Proposed Employment and Employer
Attach the Form
1. Job Title |
2. LCA or ETA Case Number |
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Form |
Page 4 of 42 |
Part 5. Basic Information About the Proposed Employment and Employer (continued)
3.Address where the beneficiary(ies) will work if different from address in Part 1.
Street Number and Name |
Apt. Ste. Flr. |
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City or Town |
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State |
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ZIP Code |
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4.Did you include an itinerary with the petition?
5.Will the beneficiary(ies) work for you
6.Will the beneficiary(ies) work exclusively in the Commonwealth of the Northern Mariana Islands (CNMI)?
7.Is this a
8. If the answer to Item Number 7. is no, how many hours per week for the position? |
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Yes
Yes
Yes
Yes
No
No
No
No
9.Wages: $
10.Other Compensation (Explain)
per (Specify hour, week, month, or year) |
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11. Dates of intended employment From: (mm/dd/yyyy)
12.Type of Business
To: (mm/dd/yyyy)
13. Year Established
14. Current Number of Employees in the United States 15. Gross Annual Income |
16. Net Annual Income |
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Part 6. Information About The Beneficiary's Public Benefits
Part 6. only applies to petitions that also seek a change of a beneficiary's status or an extension of a beneficiary's nonimmigrant stay in the United States. If you are filing this petition without a request for the beneficiary's change of status or extension of stay, you may skip Part 6.
Provide the requested information and submit documentation as outlined in the Instructions. For additional beneficiaries, please respond to the questions in Attachment 1 below.
Form |
Page 5 of 42 |
Part 6. Information About The Beneficiary's Public Benefits (continued)
1.Has the beneficiary received, since obtaining the nonimmigrant status that you seek to extend or that you seek to change on behalf of the beneficiary, received, or is the beneficiary currently certified to receive, the following public benefits? (select all that apply).
Yes, the beneficiary has received or is currently certified to receive the following public benefits: (select all that apply)
Any Federal, State, local or tribal cash assistance for income maintenance
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
General Assistance (GA)
Supplemental Nutrition Assistance Program (SNAP, formerly called “Food Stamps”)
Section 8 Housing Assistance under the Housing Choice Voucher Program
Section 8
Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.
No, the beneficiary has not received any of the above listed public benefits.
No, the beneficiary is not certified to receive any of the above listed public benefits.
2.If the beneficiary has received or is currently certified to receive any of the above public benefits, provide information about the public benefits below. If you need additional space to complete any Item Number in this Part, use the space provided in Part 10. Additional Information. Submit evidence as outlined in the Instructions.
A.Type of Benefit
Agency that Granted the Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy)
Date Benefit Ended or Expires (mm/dd/yyyy)
B.Type of Benefit
Agency that Granted the Benefit
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Date the Beneficiary Started Receiving the Benefit or if Certified, |
Date Benefit Ended or Expires |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
(mm/dd/yyyy) |
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C.Type of Benefit
Agency that Granted the Benefit
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Date the Beneficiary Started Receiving the Benefit or if Certified, |
Date Benefit Ended or Expires |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
(mm/dd/yyyy) |
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Form |
Page 6 of 42 |
Part 6. Information About The Beneficiary's Public Benefits (continued)
D.Type of Benefit
Agency that Granted the Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, |
Date Benefit Ended or Expires |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
(mm/dd/yyyy) |
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3.If you answered “Yes” to Item Number 1., do any of the following apply to the beneficiary? Provide the evidence listed in the Form
The beneficiary is enlisted in the Armed Forces, or is serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
The beneficiary is the spouse or the child of an individual who is enlisted in the Armed Forces, or who is serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
At the time the beneficiary received the public benefits, the beneficiary (or the beneficiary's spouse or parent) was enlisted in the Armed Forces, or was serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
At the time the beneficiary received the public benefits, the beneficiary was present in the United States in a status exempt from the public charge ground of inadmissibility.
At the time the beneficiary received the public benefits, the beneficiary was present in the United States after being granted a waiver of the public charge ground of inadmissibility.
The beneficiary is a child currently residing abroad who entered the United States with a nonimmigrant visa to attend an
None of the above statements apply to the beneficiary.
4.a. Has the beneficiary received, applied for, or has been certified to receive
An emergency medical condition
For a service under the Individuals with Disabilities Education Act (IDEA)
Other
While under the of age 21
While pregnant or during the
4.b. Provide the applicable dates |
From: (mm/dd/yyyy) |
To: (mm/dd/yyyy)
Form |
Page 7 of 42 |
Part 7. Certification Regarding the Release of Controlled Technology or Technical Data to Foreign Persons in the United States
(This section of the form is required only for
Select Item Number 1. or Item Number 2. as appropriate. DO NOT select both boxes.
With respect to the technology or technical data the petitioner will release or otherwise provide access to the beneficiary, the petitioner certifies that it has reviewed the Export Administration Regulations (EAR) and the International Traffic in Arms Regulations (ITAR) and has determined that:
1.
2.
A license is not required from either the U.S. Department of Commerce or the U.S. Department of State to release such technology or technical data to the foreign person; or
A license is required from the U.S. Department of Commerce and/or the U.S. Department of State to release such technology or technical data to the beneficiary and the petitioner will prevent access to the controlled technology or technical data by the beneficiary until and unless the petitioner has received the required license or other authorization to release it to the beneficiary.
Part 8. Declaration, Signature, and Contact Information of Petitioner or Authorized Signatory (Read
the information on penalties in the instructions before completing this section.)
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 U.S. Citizenship and Immigration Services (USCIS) at a later date.
I authorize the release of any information from my records, or from the petitioning organization's records that USCIS needs to determine eligibility for the immigration benefit sought. 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,
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 and that all of the information contained in the petition, including all responses to specific questions, and in the supporting documents, is complete, true, and correct.
1.Name and Title of Authorized Signatory
Family Name (Last Name) |
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Given Name (First Name) |
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2. |
Signature and Date |
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Signature of Authorized Signatory |
Date of Signature (mm/dd/yyyy) |
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3.Signatory's Contact Information
Daytime Telephone Number |
Email Address (if any) |
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NOTE: If you do not fully complete this form or fail to submit the required documents listed in the instructions, a final decision on your petition may be delayed or the petition may be denied.
Form |
Page 8 of 42 |
Part 9. Declaration, Signature, and Contact Information of Person Preparing Form, If Other Than Petitioner
Provide the following information concerning the preparer:
1.Name of Preparer
Family Name (Last Name) |
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Given Name (First Name) |
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2.Preparer's Business or Organization Name (if any)
(If applicable, provide the name of your accredited organization recognized by the Board of Immigration Appeals (BIA).)
3.Preparer's Mailing Address
Street Number and Name |
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City or Town |
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State |
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4.Preparer's Contact Information
Daytime Telephone Number |
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Fax Number |
Email Address (if any) |
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Preparer's Declaration
By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this petition on behalf of, at the request of, and with the express consent of the petitioner or authorized signatory. The petitioner has reviewed this completed petition as prepared by me and informed me that all of the information in the form and in the supporting documents, is complete, true, and correct.
5.Signature and Date
Signature of Preparer |
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Date of Signature (mm/dd/yyyy) |
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Form |
Page 9 of 42 |
Part 10. Additional Information About Your Petition For Nonimmigrant Worker
If you require more space to provide any additional information within this petition, use the space below. If you require more space than what is provided to complete this petition, you may make a copy of Part 10. to complete and file with this petition. In order to assist us in reviewing your response, you must identify the Page Number, Part Number and Item Number corresponding to the additional information.
1. |
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2. |
Page Number |
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Part Number |
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3. Page Number |
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Part Number |
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Item Number |
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4. Page Number |
Part Number |
Item Number |
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Form |
Page 10 of 42 |
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USCIS |
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Department of Homeland Security |
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OMB No. |
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U.S. Citizenship and Immigration Services |
Expires 10/31/2021 |
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1.Name of the Petitioner
2.Name of the Beneficiary
Family Name (Last Name) |
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Given Name (First Name) |
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Middle Name |
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3.Classification sought (select only one box):
4.Name of country signatory to treaty with the United States
5.Are you seeking advice from USCIS to determine whether changes in the terms or conditions of E status for one or more employees are substantive?
Yes
No
Section 1. Information About the Employer Outside the United States (if any)
1. |
Employer's Name |
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2. |
Total Number of Employees |
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3. |
Employer's Address |
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Street Number and Name |
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Apt. Ste. Flr. |
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Number |
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City or Town |
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4.Principal Product, Merchandise or Service
5.Employee's Position - Title, duties and number of years employed
Form |
Page 11 of 42 |
Section 2. Additional Information About the U.S. Employer
1.How is the U.S. company related to the company abroad? (select only one box)
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Parent |
Branch |
Subsidiary |
Affiliate |
Joint Venture |
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2.a. Place of Incorporation or Establishment in the United States |
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2.b. Date of incorporation or establishment |
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(mm/dd/yyyy) |
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3.Nationality of Ownership (Individual or Corporate)
Name (First/MI/Last) |
Nationality |
Immigration Status |
Percent of |
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Ownership |
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4. Assets |
5. Net Worth |
6. Net Annual Income |
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7.Staff in the United States
a.How many executive and managerial employees does the petitioner have who are nationals of the treaty country in either E, L, or H nonimmigrant status?
b.How many persons with special qualifications does the petitioner employ who are in either E, L, or H nonimmigrant status?
c. Provide the total number of employees in executive and managerial positions in the United States.
d. Provide the total number of positions in the United States that require persons with special qualifications.
8.If the petitioner is attempting to qualify the employee as an executive or manager, provide the total number of employees he or she will supervise. Or, if the petitioner is attempting to qualify the employee based on special qualifications, explain why the special qualifications are essential to the successful or efficient operation of the treaty enterprise.
Section 3. Complete If Filing for an
1. |
Total Annual Gross Trade/ |
2. For Year Ending |
3. Percent of total gross trade between the United States and the |
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Business of the U.S. company |
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treaty trader country. |
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Section 4. Complete If Filing for an
Total Investment: Cash |
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Equipment |
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Other |
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Inventory |
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Premises |
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Total |
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Form |
Page 12 of 42 |
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Trade Agreement Supplement to Form |
USCIS |
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Department of Homeland Security |
Form |
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OMB No. |
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U.S. Citizenship and Immigration Services |
Expires 10/31/2021 |
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1.Name of the Petitioner
2.Name of the Beneficiary
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Employer is a (select only one box): |
4. If Foreign Employer, Name the Foreign Country |
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U.S. Employer |
Foreign Employer |
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Section 1. Information About Requested Extension or Change (See instructions attached to this form.)
1.This is a request for Free Trade status based on (select only one box):
a. |
Free Trade, Canada (TN1) |
d. |
Free Trade, Singapore |
b. |
Free Trade, Mexico (TN2) |
e. |
Free Trade, Other |
c. |
Free Trade, Chile |
f. |
A sixth consecutive request for Free Trade, Chile or |
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Singapore |
Section 2. Petitioner's Declaration, Signature, and Contact Information (Read the information on
penalties in the instructions before completing this section.)
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 U.S. Citizenship and Immigration Services (USCIS) at a later date.
I authorize the release of any information from my records, or from the petitioning organization's records that USCIS needs to determine eligibility for the immigration benefit sought. 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,
I certify, under penalty of perjury, that I have reviewed this petition and that all of the information contained on the petition, including all responses to specific questions, and in the supporting documents, is complete, true, and correct.
I am filing this petition on behalf of an organization and I certify that I am authorized to do so by the organization.
1.Name of Petitioner
Family Name (Last Name) |
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Given Name (First Name) |
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2.Signature and Date
Signature of Petitioner |
Date of Signature (mm/dd/yyyy) |
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3.Petitioner's Contact Information
Daytime Telephone Number |
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Mobile Telephone Number |
Email Address (if any) |
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Form |
Trade Agreement Supplement |
Page 13 of 42 |
Section 3. Declaration, Signature, and Contact Information of Person Preparing Form, If Other Than Petitioner
Provide the following information concerning the preparer: |
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1. Name of Preparer |
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Family Name (Last Name) |
Given Name (First Name) |
2.Preparer's Business or Organization Name (if any)
(If applicable, provide the name of your accredited organization recognized by the Board of Immigration Appeals (BIA)).
3.Preparer's Mailing Address
Street Number and Name |
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Apt. Ste. Flr. |
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Number |
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City or Town |
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State |
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ZIP Code |
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Province |
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Postal Code |
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4.Preparer's Contact Information
Daytime Telephone Number |
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Fax Number |
Email Address (if any) |
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Preparer's Declaration
By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this petition on behalf of, at the request of, and with the express consent of the petitioner or authorized signatory. The petitioner has reviewed this completed petition as prepared by me and informed me that all of the information in the form and in the supporting documents, is complete, true, and correct.
5. |
Signature and Date |
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Signature of Preparer |
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Date of Signature (mm/dd/yyyy) |
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Form |
Trade Agreement Supplement |
Page 14 of 42 |
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H Classification Supplement to Form |
USCIS |
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Department of Homeland Security |
Form |
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OMB No. |
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U.S. Citizenship and Immigration Services |
Expires 10/31/2021 |
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1.Name of the Petitioner
Name of the beneficiary or if this petition includes multiple beneficiaries, the total number of beneficiaries
2.a. Name of the Beneficiary
OR
2.b. Provide the total number of beneficiaries
3.List each beneficiary's prior periods of stay in H or L classification in the United States for the last six years (beneficiaries requesting
NOTE: Submit photocopies of Forms
Subject's Name
Period of Stay (mm/dd/yyyy)
From To
4.Classification sought (select only one box):
a.
c.
d.
f.
h.
5.If you selected a. or d. in Item Number 4., and are filing an
6.Are you filing this petition on behalf of a beneficiary subject to the
Yes |
No |
Form |
H Classification Supplement |
Page 15 of 42 |
7.Are you requesting a change of employer and was the beneficiary previously subject to the
Yes
No
8.a. Does any beneficiary in this petition have ownership interest in the petitioning organization?
Yes. If yes, please explain in Item Number 8.b.
No
8.b. Explanation
Section 1. Complete This Section If Filing for
1.Describe the proposed duties.
2.Describe the beneficiary's present occupation and summary of prior work experience.
Statement for
By filing this petition, I agree to, and will abide by, the terms of the labor condition application (LCA) for the duration of the beneficiary's authorized period of stay for
I further understand that I cannot charge the beneficiary the ACWIA fee, and that any other required reimbursement will be considered an offset against wages and benefits paid relative to the LCA.
Signature of Petitioner |
Name of Petitioner |
Date (mm/dd/yyyy) |
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Statement for
As an authorized official of the employer, I certify that the employer will be liable for the reasonable costs of return transportation of the alien abroad if the beneficiary is dismissed from employment by the employer before the end of the period of authorized stay.
Signature of Authorized Official of Employer |
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Name of Authorized Official of Employer |
Date (mm/dd/yyyy) |
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Statement for
I certify that the beneficiary will be working on a cooperative research and development project or a
Signature of DOD Project Manager |
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Name of DOD Project Manager |
Date (mm/dd/yyyy) |
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Form |
H Classification Supplement |
Page 16 of 42 |
Section 2. Complete This Section If Filing for
1.Employment is: (select only one box)
a. Seasonal |
b. Peak load |
2.Temporary need is: (select only one box)
c.Intermittent
d.
a.Unpredictable
b.Periodic
c. Recurrent annually
3.Explain your temporary need for the workers' services (Attach a separate sheet if additional space is needed).
4.List the countries of citizenship for the
5.a. You must provide all of the requested information for Item Numbers 5.a. - 6. for each
Family Name (Last Name) |
Given Name (First Name) |
Middle Name |
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5.b. Provide all other name(s) used
Family Name (Last Name) |
Given Name (First Name) |
Middle Name |
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5.c. Date of Birth (mm/dd/yyyy) 5.d. Country of Birth
5.e. Country of Citizenship or Nationality
6.a. Have any of the workers listed in Item Number 5. above ever been admitted to the United States previously in
Yes. If yes, go to Part 10. of Form
No
6.b. Visa Classification
NOTE: If any of the
list, you must also provide evidence showing: (1) that workers with the required skills are not available from a country currently on the eligible countries list*; (2) whether the beneficiaries have been admitted previously to the United States in
*For
Form |
H Classification Supplement |
Page 17 of 42 |
Section 2. Complete This Section If Filing for
7.a. Did you or do you plan to use a staffing, recruiting, or similar placement service or agent to locate the
Yes
No
If yes, list the name and address of service or agent used below. Please use Part 10. of Form
7.b. Name
7.c. Address |
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Street Number and Name |
Apt. Ste. Flr. |
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Number |
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City or Town |
State |
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ZIP Code |
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8.a. Did any of the
Yes
No
8.b. If yes, list the types and amounts of fees that the worker(s) paid or will pay.
8.c. |
If the workers paid any fee or compensation, were they reimbursed? |
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Yes |
No |
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8.d. If the workers agreed to pay a fee that they have not yet been paid, has their agreement been terminated |
Yes |
No |
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before the workers paid the fee? (Submit evidence of termination or reimbursement with this petition.) |
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9. |
Have you made reasonable inquiries to determine that to the best of your knowledge the recruiter, |
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No |
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facilitator, or similar employment service that you used has not collected, and will not collect, directly or |
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indirectly, any fees or other compensation from the |
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workers' employment? |
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NOTE: If USCIS determines that you knew, or should have known, that the workers requested in |
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connection with this petition paid any fees or other compensation at any time as a condition of |
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employment, your petition may be denied or revoked. |
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10.a. Have you ever had an |
Yes |
No |
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fee or other similar compensation as a condition of the job offer or employment? |
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10.a.1 |
If yes, when? |
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10.a.2 |
Receipt Number: ► |
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10.b. Were the workers reimbursed for such fees and compensation? (Submit evidence of reimbursement.) |
If |
Yes |
No |
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you answered no because you were unable to locate the workers, include evidence of your efforts to locate |
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the workers. |
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Form |
H Classification Supplement |
Page 18 of 42 |
Section 2. Complete This Section If Filing for
11.Have any of the workers you are requesting experienced an interrupted stay associated with their entry as an
If yes, document the workers' periods of stay in the table on the first page of this supplement. Submit evidence of each entry and each exit, with the petition, as evidence of the interrupted stays.
12.a. If you are an
12.b. If yes, provide the
Yes
Yes
No
No
The
The petitioner must execute Part A. If the petitioner is the employer's agent, the employer must execute Part B. If there are joint employers, they must each execute Part C.
For
Part A. Petitioner
By filing this petition, I agree to the conditions of
Signature of Petitioner |
Name of Petitioner |
Date (mm/dd/yyyy) |
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Part B. Employer who is not the petitioner
I certify that I have authorized the party filing this petition to act as my agent in this regard. I assume full responsibility for all representations made by this agent on my behalf and agree to the conditions of
Signature of EmployerName of EmployerDate (mm/dd/yyyy)
Part C. Joint Employers
I agree to the conditions of
Signature of Joint Employer |
Name of Joint Employer |
Date (mm/dd/yyyy) |
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Signature of Joint Employer |
Name of Joint Employer |
Date (mm/dd/yyyy) |
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Signature of Joint Employer |
Name of Joint Employer |
Date (mm/dd/yyyy) |
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Signature of Joint Employer |
Name of Joint Employer |
Date (mm/dd/yyyy) |
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Form |
H Classification Supplement |
Page 19 of 42 |
Section 3. Complete This Section If Filing for
If you answer yes to any of the following questions, attach a full explanation. |
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1. |
Is the training you intend to provide, or similar training, available in the beneficiary's country? |
Yes |
2. |
Will the training benefit the beneficiary in pursuing a career abroad? |
Yes |
3. |
Does the training involve productive employment incidental to the training? If yes, explain the |
Yes |
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amount of compensation employment versus the classroom in Part 10. of Form |
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4. |
Does the beneficiary already have skills related to the training? |
Yes |
5. |
Is this training an effort to overcome a labor shortage? |
Yes |
6. |
Do you intend to employ the beneficiary abroad at the end of this training? |
Yes |
7.If you do not intend to employ the beneficiary abroad at the end of this training, explain why you wish to incur the cost of providing this training and your expected return from this training.
No
No
No
No
No
No
Form |
H Classification Supplement |
Page 20 of 42 |
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Filing Fee Exemption Supplement |
USCIS |
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Department of Homeland Security |
Form |
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OMB No. |
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U.S. Citizenship and Immigration Services |
Expires 10/31/2021 |
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1.Name of the Petitioner
2.Name of the Beneficiary
Section 1. General Information
1.Employer Information - (select all items that apply)
a.Is the petitioner an
b.Has the petitioner ever been found to be a willful violator?
c.Is the beneficiary an
c.1. If yes, is it because the beneficiary's annual rate of pay is equal to at least $60,000?
c.2. Or is it because the beneficiary has a master's degree or higher degree in a specialty related to the employment?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
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d. Does the petitioner employ 50 or more individuals in the United States? |
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Yes |
No |
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d.1. If yes, are more than 50 percent of those employees in |
Yes |
No |
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status? |
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2. Beneficiary's Highest Level of Education (select only one box) |
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a. NO DIPLOMA |
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f. Bachelor's degree (for example: BA, AB, BS) |
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b. HIGH SCHOOL GRADUATE DIPLOMA or |
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g. Master's degree (for example: MA, MS, MEng, MEd, |
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the equivalent (for example: GED) |
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MSW, MBA) |
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c. Some college credit, but less than 1 year |
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h. Professional degree (for example: MD, DDS, DVM, LLB, JD) |
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d. One or more years of college, no degree |
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i. Doctorate degree (for example: PhD, EdD) |
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e. Associate's degree (for example: AA, AS) |
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3. Major/Primary Field of Study |
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4. Rate of Pay Per Year |
5. DOT Code |
6. NAICS Code |
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Section 2. Fee Exemption and/or Determination
In order for USCIS to determine if you must pay the additional $1,500 or $750 American Competitiveness and Workforce Improvement Act (ACWIA) fee, answer all of the following questions:
1. |
Are you an institution of higher education as defined in section 101(a) of the Higher |
Yes |
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Education Act of 1965, 20 U.S.C. 1001(a)? |
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2. |
Are you a nonprofit organization or entity related to or affiliated with an institution of higher education, |
Yes |
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as defined in 8 CFR 214.2(h)(19)(iii)(B)? |
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No
No
Form |
Page 21 of 42 |
Section 2. Fee Exemption and/or Determination (continued)
3.Are you a nonprofit research organization or a governmental research organization, as defined in 8 CFR 214.2(h)(19)(iii)(C)?
4.Is this the second or subsequent request for an extension of stay that this petitioner has filed for this alien?
5.Is this an amended petition that does not contain any request for extensions of stay?
6.Are you filing this petition to correct a USCIS error?
7.Is the petitioner a primary or secondary education institution?
8.Is the petitioner a nonprofit entity that engages in an established
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
If you answered yes to any of the questions above, you are not required to submit the ACWIA fee for your
9.Do you currently employ a total of 25 or fewer
Yes
No
If you answered yes, to Item Number 9. above, you are required to pay an additional ACWIA fee of $750. If you answered no, then you are required to pay an additional ACWIA fee of $1,500.
NOTE: A petitioner seeking initial approval of
The Fraud Prevention and Detection Fee and Public Law
Section 3. Numerical Limitation Information
1.Specify the type of
c. CAP
2.If you answered Item Number 1.b. "CAP
a.Name of the United States Institution of Higher Education
b.Date Degree Awarded c. Type of United States Degree
d.Address of the United States institution of higher education
Street Number and Name |
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Apt. Ste. Flr. |
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Form |
Page 22 of 42 |
Section 3. Numerical Limitation Information (continued)
3.If you answered Item Number 1.d. "CAP Exempt," you must specify the reason(s) this petition is exempt from the numerical limitation for
a. The petitioner is an institution of higher education as defined in section 101(a) of the Higher Education Act, of 1965, 20 U.S.C. 1001(a).
b. The petitioner is a nonprofit entity related to or affiliated with an institution of higher education as defined in 8 CFR 214.2(h)(8)(ii)(F)(2).
c. The petitioner is a nonprofit research organization or a governmental research organization as defined in 8 CFR 214.2(h)(8)(ii)(F)(3).
d. The beneficiary will be employed at a qualifying cap exempt institution, organization or entity pursuant to 8 CFR 214.2(h)(8)(ii)(F)(4).
e. The petitioner is requesting an amendment to or extension of stay for the beneficiary's current
f. The beneficiary of this petition is a
g. The beneficiary of this petition has been counted against the cap and (1) is applying for the remaining portion of the 6 year period of admission, or (2) is seeking an extension beyond the
h. The petitioner is an employer subject to the
Section 4.
1.The beneficiary of this petition will be assigned to work at an
If no, do not complete Item Numbers 2. and 3.
2.Placement of the beneficiary
3.The beneficiary will be paid the higher of the prevailing or actual wage at any and all
Yes
Yes
Yes
No
No
No
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Page 23 of 42 |
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L Classification Supplement to Form |
USCIS |
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U.S. Citizenship and Immigration Services |
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1.Name of the Petitioner
2.Name of the Beneficiary
3.This petition is (select only one box):
a. An individual petition
b. A blanket petition
4.a. Does the petitioner employ 50 or more individuals in the U.S.?
Yes
No
4.b. If yes, are more than 50 percent of those employee in
Yes
No
Section 1. Complete This Section If Filing For An Individual Petition
1. |
Classification sought (select only one box): |
a. |
b. |
2.List the beneficiary's and any dependent family member's prior periods of stay in an H or L classification in the United States for the last seven years. Be sure to list only those periods in which the beneficiary and/or family members were physically present in the U.S. in an H or L classification. Do not include periods in which the beneficiary was in a dependent status, for example,
NOTE: Submit photocopies of Forms
Subject's Name
Period of Stay (mm/dd/yyyy)
From To
3.Name of Employer Abroad
4.Address of Employer Abroad
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L Classification Supplement |
Page 24 of 42 |
Section 1. Complete This Section If Filing For An Individual Petition (continued)
5.Dates of beneficiary's employment with this employer. Explain any interruptions in employment.
Dates of Employment (mm/dd/yyyy)
From To
Explanation of Interruptions
6.Describe the beneficiary's duties abroad for the 3 years preceding the filing of the petition. (If the beneficiary is currently inside the United States, describe the beneficiary's duties abroad for the 3 years preceding the beneficiary's admission to the United States.)
7.Describe the beneficiary's proposed duties in the United States.
8.Summarize the beneficiary's education and work experience.
9.How is the U.S. company related to the company abroad? (select only one box)
a. Parent |
b. Branch |
c. Subsidiary |
d. Affiliate |
e. Joint Venture
Form |
L Classification Supplement |
Page 25 of 42 |
Section 1. Complete This Section If Filing For An Individual Petition (continued)
10.Describe the percentage of stock ownership and managerial control of each company that has a qualifying relationship. Provide the Federal Employer Identification Number for each U.S. company that has a qualifying relationship.
Percentage of company stock ownership and managerial control of each company that has a qualifying relationship.
Federal Employer Identification Number for each U.S. company that has a qualifying relationship
11.Do the companies currently have the same qualifying relationship as they did during the
Yes
No. If no, provide an explanation in Part 10. of Form
12.Is the beneficiary coming to the United States to open a new office?
Yes
No (attach explanation)
If you are seeking
13.a. Will the beneficiary be stationed primarily offsite (at the worksite of an employer other than the petitioner or its affiliate, subsidiary, or parent)?
Yes
No
13.b. If you answered yes to the preceding question, describe how and by whom the beneficiary's work will be controlled and supervised. Include a description of the amount of time each supervisor is expected to control and supervise the work. If you need additional space to respond to this question, proceed to Part 10. of the Form
13.c. If you answered yes to the preceding question, describe the reasons why placement at another worksite outside the petitioner, subsidiary, affiliate, or parent is needed. Include a description of how the beneficiary's duties at another worksite relate to the need for the specialized knowledge he or she possesses. If you need additional space to respond to this question, proceed to Part 10. of the Form
Form |
L Classification Supplement |
Page 26 of 42 |
Section 2. Complete This Section If Filing A Blanket Petition
List all U.S. and foreign parent, branches, subsidiaries, and affiliates included in this petition. (Attach separate sheets of paper if additional space is needed.)
Name and Address
Relationship
Section 3. Additional Fees
NOTE: A petitioner that seeks initial approval of L nonimmigrant status for a beneficiary, or seeks approval to employ an L nonimmigrant currently working for another employer, must submit an additional $500 Fraud Prevention and Detection fee. For petitions filed on or after December 18, 2015, you must submit an additional fee of $4,500 if you responded yes to both questions in Item Numbers 4.a. and 4.b. on the first page of this L Classification Supplement. This $4,500 fee is mandated by the provisions of Public Law
These fees, when applicable, may not be waived. You must include payment of the fees with your submission of this form. Failure to submit the fees when required will result in rejection or denial of your submission. Each of these fees should be paid by separate checks or money orders.
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L Classification Supplement |
Page 27 of 42 |
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O and P Classifications Supplement to Form |
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Expires 10/31/2021 |
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Section 1. Complete This Section if Filing for O or P Classification
1.Name of the Petitioner
Name of the Beneficiary or if this petition includes multiple beneficiaries, the total number of beneficiaries included.
2.a. Name of the Beneficiary
OR
2.b. Provide the total number of beneficiaries:
3.Classification sought (select only one box)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
4.Explain the nature of the event.
5.Describe the duties to be performed.
6.If filing for an
7.a. Does any beneficiary in this petition have ownership interest in the petitioning organization?
Yes. If yes, please explain in Item Number 7.b. |
No. |
Form |
O and P Classifications Supplement |
Page 28 of 42 |
Section 1. Complete This Section if Filing for O or P Classification (continued)
7.b. Explanation
8.Does an appropriate labor organization exist for the petition?
Yes |
No. If no, proceed to Part 10. and type or print your explanation. |
9.Is the required consultation or written advisory opinion being submitted with this petition?
Yes
No - copy of request attached
N/A
If no, provide the following information about the organization(s) to which you have sent a duplicate of this petition.
10.a. Name of Recognized Peer/Peer Group or Labor Organization
10.b. Physical Address |
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11.a. Name of Labor Organization
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12.a. Name of Management Organization
12.b. Physical Address |
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Form |
O and P Classifications Supplement |
Page 29 of 42 |
Section 1. Complete This Section if Filing for O or P Classification (continued)
13.a. Name of Labor Organization
13.b. Complete Address |
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Street Number and Name |
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Section 2. Statement by the Petitioner
I certify that I, the petitioner, and the employer whose offer of employment formed the basis of status (if different from the petitioner) will be jointly and severally liable for the reasonable costs of return transportation of the beneficiary abroad if the beneficiary is dismissed from employment by the employer before the end of the period of authorized stay.
1. Name of Petitioner |
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Signature and Date |
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3.Petitioner's Contact Information
Daytime Telephone Number |
Email Address (if any) |
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O and P Classifications Supplement |
Page 30 of 42 |
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Department of Homeland Security |
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1.Name of the Petitioner
2.Name of the Beneficiary
Section 1. Complete if you are filing for a
I hereby certify that the participant(s) in the international cultural exchange program:
a.Is at least 18 years of age,
b.Is qualified to perform the service or labor or receive the type of training stated in the petition,
c.Has the ability to communicate effectively about the cultural attributes of his or her country of nationality to the American public, and
d.Has resided and been physically present outside the United States for the immediate prior year. (Applies only if the participant was previously admitted as a
I also certify that I will offer the alien(s) the same wages and working conditions comparable to those accorded local domestic workers similarly employed.
1. Name of Petitioner |
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Given Name (First Name) |
Middle Name |
2.Signature and Date
Signature of Petitioner |
Date of Signature (mm/dd/yyyy) |
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3.Petitioner's Contact Information
Daytime Telephone Number |
Email Address (if any) |
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Page 31 of 42 |
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Department of Homeland Security |
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OMB No. |
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U.S. Citizenship and Immigration Services |
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1.Name of the Petitioner
2.Name of the Beneficiary
Section 1. Complete This Section If You Are Filing For An
Employer Attestation
Provide the following information about the petitioner:
1.a. Number of members of the petitioner's religious organization?
1.b. Number of employees working at the same location where the beneficiary will be employed?
1.c. Number of aliens holding special immigrant or nonimmigrant religious worker status currently employed or employed within the past five years?
1.d. Number of special immigrant religious worker petition(s)
2.Has the beneficiary or any of the beneficiary's dependent family members previously been admitted to the United States for a period of stay in the R visa classification in the last five years?
Yes
No
If yes, complete the spaces below. List the beneficiary and any dependent family member’s prior periods of stay in the R visa classification in the United States in the last five years. Please be sure to list only those periods in which the beneficiary and/or family members were actually in the United States in an R classification.
NOTE: Submit photocopies of Forms
Alien or Dependent Family Member's Name
Period of Stay (mm/dd/yyyy)
From To
Form |
Page 32 of 42 |
Section 1. Complete This Section If You Are Filing For An
3.Provide a summary of the type of responsibilities of those employees who work at the same location where the beneficiary will be employed. If additional space is needed, provide the information on additional sheet(s) of paper.
Position
Summary of the Type of Responsibilities for That Position
4.Describe the relationship, if any, between the religious organization in the United States and the organization abroad of which the beneficiary is a member.
Provide the following information about the prospective employment:
5.a. Title of position offered.
5.b. Detailed description of the beneficiary's proposed daily duties.
5.c. Description of the beneficiary's qualifications for position offered.
5.d. Description of the proposed salaried compensation or
Form |
Page 33 of 42 |
Section 1. Complete This Section If You Are Filing For An
5.e. List of the address(es) or location(s) where the beneficiary will be working.
Petitioner Attestations
Does the petitioner attest to all of the requirements described in Item Numbers 6. - 12. below?
6.The petitioner is a bona fide
Yes
No. If no, type or print your explanation below and if needed, go to Part 10. of Form
7.The petitioner is willing and able to provide salaried or
Yes
No. If no, type or print your explanation below and if needed, go to Part 10. of Form
8.If the beneficiary worked in the United States in an
Yes
No. If no, type or print your explanation below and if needed, go to Part 10. of Form
9.If the position is not a religious vocation, the beneficiary will not engage in secular employment, and the petitioner will provide salaried or
Yes
No. If no, type or print your explanation below and if needed, go to Part 10. of Form
Form |
Page 34 of 42 |
Section 1. Complete This Section If You Are Filing For An
10.The offered position requires at least 20 hours of work per week. If the offered position at the petitioning organization requires fewer than 20 hours per week, the compensated service for another religious organization and the compensated service at the petitioning organization will total 20 hours per week. If the beneficiary will be
Yes
No. If no, type or print your explanation below and if needed, go to Part 10. of Form
11.The beneficiary has been a member of the petitioner's denomination for at least two years immediately before Form
Yes
No. If no, type or print your explanation below and if needed, go to Part 10. of Form
12.The petitioner will notify USCIS within 14 days if an
Yes
No. If no, type or print your explanation below and if needed, go to Part 10. of Form
Attestation
I certify, under penalty of perjury, that the contents of this attestation and the evidence submitted with it are true and correct.
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Page 35 of 42 |
Section 1. Complete This Section If You Are Filing For An
Employer or Organization Address (do not use a post office or private mail box)
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Employer or Organization's Contact Information
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Section 2. This Section Is Required For Petitioners Affiliated With The Religious Denomination
Religious Denomination Certification
I certify, under penalty of perjury, that:
Name of Employing Organization
is affiliated with:
Name of Religious Denomination
and that the attesting organization within the religious denomination is
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Attesting Organization Name and Address (do not use a post office or private mail box)
Attesting Organization Name
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Page 36 of 42 |
Attach to Form
include the person you named on the Form
Family Name (Last Name) |
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Date of birth (mm/dd/yyyy) Gender Male
U.S. Social Security Number (if any) Female ►
A-
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Address in the United States Where You Intend to Live (Complete Address)
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IF IN THE UNITED STATES:
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Form |
Page 37 of 42 |
Information About the Additional Beneficiary's Public Benefits
1.Has the beneficiary, since obtaining the nonimmigrant status that you seek to extend or that you seek to change on behalf of the beneficiary, received, or is the beneficiary currently certified to receive, any of the following public benefits? (select all that apply).
Yes, the beneficiary has received or is currently certified to receive the following public benefits:
Any Federal, State, local or tribal cash assistance for income maintenance
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
General Assistance (GA)
Supplemental Nutrition Assistance Program (SNAP, formerly called “Food Stamps”)
Section 8 Housing Assistance under the Housing Choice Voucher Program
Section 8
Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.
No, the beneficiary has not received any of the above listed public benefits.
No, the beneficiary is not certified to receive any of the above listed public benefits.
2.If the beneficiary has received or is currently certified to receive any of the above public benefits, provide information about the public benefits below. If you need additional space to complete any Item Number in this Part, use the space provided in Part 10. Additional Information. Submit evidence as outlined in the Instructions.
A.Type of Benefit
Agency that Granted the Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy)
Date Benefit Ended or Expires (mm/dd/yyyy)
B.Type of Benefit
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C.Type of Benefit
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Date the Beneficiary Started Receiving the Benefit or if Certified, |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
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Form |
Page 38 of 42 |
Information About the Additional Beneficiary's Public Benefits (continued)
D.Type of Benefit
Agency that Granted the Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, |
Date Benefit Ended or Expires |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
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3.If you answered “Yes” to Item Number 1., do any of the following apply to the beneficiary? Provide the evidence listed in the Form
The beneficiary is enlisted in the Armed Forces, or is serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
The beneficiary is the spouse or the child of an individual who is enlisted in the Armed Forces, or is serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
At the time the beneficiary received the public benefits, the beneficiary (or the beneficiary's spouse or parent) was enlisted in the Armed Forces, or was serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
At the time the beneficiary received the public benefits, the beneficiary was present in the United States in a status exempt from the public charge ground of inadmissibility.
At the time the beneficiary received the public benefits, the beneficiary was present in the United States after being granted a waiver of the public charge ground of inadmissibility.
The beneficiary is a child currently residing abroad who entered the United States with a nonimmigrant visa to attend an
None of the above statements apply to the beneficiary.
4.Has the beneficiary received, applied for, or has been certified to receive
An emergency medical condition
For a service under the Individuals with Disabilities Education Act (IDEA)
Other
While under the of age 21
While pregnant or during the
5. |
Provide the applicable dates |
From: (mm/dd/yyyy) |
To: (mm/dd/yyyy)
Form |
Page 39 of 42 |
Attach to Form
include the person you named on the Form
Family Name (Last Name) |
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Date of birth (mm/dd/yyyy) Gender Male
U.S. Social Security Number (if any) Female ►
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All Other Names Used (include aliases, maiden name and names from previous Marriages)
Family Name (Last Name) |
Given Name (First Name) |
Middle Name |
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Address in the United States Where You Intend to Live (Complete Address)
Street Number and Name
City or Town
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Foreign Address (Complete Address)
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City or Town |
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Country of Citizenship or Nationality |
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IF IN THE UNITED STATES:
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Passport or Travel Document |
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Date Passport or Travel Document |
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or Travel Document |
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Current Nonimmigrant Status |
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Student and Exchange Visitor Information System (SEVIS) Number |
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Form |
Page 40 of 42 |
Information About the Additional Beneficiary's Public Benefits
1.Has the beneficiary, since obtaining the nonimmigrant status that you seek to extend or that you seek to change on behalf of the beneficiary, received, or is the beneficiary currently certified to receive, any of the following public benefits? (select all that apply).
Yes, the beneficiary has received or is currently certified to receive the following public benefits:
Any Federal, State, local or tribal cash assistance for income maintenance
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
General Assistance (GA)
Supplemental Nutrition Assistance Program (SNAP, formerly called “Food Stamps”)
Section 8 Housing Assistance under the Housing Choice Voucher Program
Section 8
Public Housing under the Housing Act of 1937, 42 U.S.C. 1437 et seq.
No, the beneficiary has not received any of the above listed public benefits.
No, the beneficiary is not certified to receive any of the above listed public benefits.
2.If the beneficiary has received or is currently certified to receive any of the above public benefits, provide information about the public benefits below. If you need additional space to complete any Item Number in this Part, use the space provided in Part 10. Additional Information. Submit evidence as outlined in the Instructions.
A.Type of Benefit
Agency that Granted the Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy)
Date Benefit Ended or Expires (mm/dd/yyyy)
B.Type of Benefit
Agency that Granted the Benefit
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Date the Beneficiary Started Receiving the Benefit or if Certified, |
Date Benefit Ended or Expires |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
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C.Type of Benefit
Agency that Granted the Benefit
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Date the Beneficiary Started Receiving the Benefit or if Certified, |
Date Benefit Ended or Expires |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
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Form |
Page 41 of 42 |
Information About the Additional Beneficiary's Public Benefits (continued)
D.Type of Benefit
Agency that Granted the Benefit
Date the Beneficiary Started Receiving the Benefit or if Certified, |
Date Benefit Ended or Expires |
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Date the Beneficiary Will Start Receiving the Benefit (mm/dd/yyyy) |
(mm/dd/yyyy) |
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3.If you answered “Yes” to Item Number 1., do any of the following apply to the beneficiary? Provide the evidence listed in the Form
The beneficiary is enlisted in the Armed Forces, or is serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
The beneficiary is the spouse or the child of an individual who is enlisted in the Armed Forces, or is serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
At the time the beneficiary received the public benefits, the beneficiary (or the beneficiary's spouse or parent) was enlisted in the Armed Forces, or was serving in active duty or in the Ready Reserve Component of the U.S. Armed Forces.
At the time the beneficiary received the public benefits, the beneficiary was present in the United States in a status exempt from the public charge ground of inadmissibility.
At the time the beneficiary received the public benefits, the beneficiary was present in the United States after being granted a waiver of the public charge ground of inadmissibility.
The beneficiary is a child currently residing abroad who entered the United States with a nonimmigrant visa to attend an
None of the above statements apply to the beneficiary.
4.Has the beneficiary received, applied for, or has been certified to receive
An emergency medical condition
For a service under the Individuals with Disabilities Education Act (IDEA)
Other
While under the of age 21
While pregnant or during the
5. |
Provide the applicable dates |
From: (mm/dd/yyyy) |
To: (mm/dd/yyyy)
Form |
Page 42 of 42 |