G28 Form – Fill Out and Use

Part 1. Information About Attorney or Accredited Representative

Name and Address of Attorney or Accredited Representative

1.a. Family Name

(Last Name)

1.b. Given Name

(First Name)

1.c. Middle Name

2.Name of Law Firm or Recognized Organization

3.Name of Law Student or Law Graduate

4.State Bar Number

Part 2. Eligibility Information For Attorney or Accredited Representative

(Check applicable items(s) below)

1. I am an attorney eligible to practice law in, and a member in good standing of, the bar of the highest court(s) of the following State(s), possession(s), territory(ies), commonwealth(s), or the District of Columbia.

1.a.

1.b. I (choose one) AM NOT AM

subject to any order of any court or administrative agency disbarring, suspending, enjoining, restraining, or otherwise restricting me in the practice of law. (If you are subject to any order(s), explain fully in the space below.)

1.b.1.

2. I am an accredited representative of the following qualified nonprofit religious, charitable, social service, or similar organization established in the United States, so recognized by the Department of Justice, Board of Immigration Appeals pursuant to 8 CFR 292.2. Provide the name of the organization and the expiration date of accreditation.

5.e. State

5.g. Postal Code

5.h. Province 5.i. Country

5.f. Zip Code

2.a. Name of Recognized Organization

7.E-Mail Address of Attorney or Accredited Representative

the attorney or accredited representative of record who previously filed Form G-28 in this case, and my appearance as an attorney or accredited representative is at his or her request. If you check this item, also complete number 1 (1.a. - 1.b.1.) or number 2 (2.a.

- 2.b.) in Part 2 (whichever is appropriate).

4. I am a law student or law graduate working under the direct supervision of the attorney or accredited representative of record on this form in accordance with the requirements in 8 CFR 292.1(a)(2)(iv).

Part 3. Notice of Appearance as Attorney or Accredited Representative

This appearance relates to immigration matters before (select one):

1.a.

2. ICE - List the specific matter in which appearance is entered

2.a.

3. CBP - List the specific matter in which appearance is entered

3.a.

I hereby enter my appearance as attorney or accredited representative at the request of:

Respondent (ICE, CBP)

Name of Applicant, Petitioner, or Respondent

5.a. Family Name

(Last Name)

5.b. Given Name

(First Name)

5.c. Middle Name

5.d. Name of Company or Organization, if applicable

NOTE: Provide the mailing address of Petitioner, Applicant,or Respondent and not the address of the attorney or accredited

representative, except when a safe mailing address is

permitted on an application or petition filed with Form G-28.

7.Provide A-Number and/or Receipt Number

Pursuant to the Privacy Act of 1974 and DHS policy, I hereby consent to the disclosure to the named Attorney or Accredited Representative of any record pertaining to me that appears in any system of records of USCIS, ICE, or CBP.

8.a. Signature of Applicant, Petitioner, or Respondent

Part 4. Signature of Attorney or Accredited Representative

I have read and understand the regulations and conditions contained in 8 CFR 103.2 and 292 governing appearances and representation before the Department of Homeland Security. I declare under penalty of perjury under the laws of the United States that the information I have provided on this form is true and correct.

1.Signature of Attorney or Accredited Representative

2.Signature of Law Student or Law Graduate

3.Date (mm/dd/yyyy) ►

Part 5. Additional Information

1.