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Item Numbers 6.a. - 6.e. - The mailing address of the applicant, petitioner, or respondent, and not the address of the

attorney or accredited representative, is required in this part of the form except when a safe mailing address is

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

Item Number 7. - Provide the A-Number or USCIS Receipt/Case Number, if applicable, for the applicant, petitioner, or

respondent.

Item Numbers 8.a. - 8.b. - The applicant, petitioner, or respondent must sign and date the form in black ink.

Part 4. Signature of Attorney or Accredited Representative

Item Numbers 1. - 3. - The attorney or accredited representative, or law student or law graduate must sign and date the

form in black ink.

Part 5. Additional Information

Please use this section to provide additional information.

Warning

Individuals appearing as attorneys or accredited representatives (including law students and law graduates permitted to

appear under 8 CFR 292.1(a)(2)) are subject to the rules of Professional Conduct for Practitioners found in 8 CFR 292.3.

Freedom of Information/Privacy Act Requests

This form may not be used to request records under the Freedom of Information Act or the Privacy Act 5 U.S.C. 552 and

552a. The procedures for requesting such records are contained in 6 CFR Part 5 and may be found at

USCIS Privacy Act Statement

AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the

Immigration and Nationality Act, section 101, et seq.

PURPOSE: The primary purpose for providing the requested information on this form is to determine if you have

established eligibility for the immigration benefit for which you are filing. The information you provide will be used to

grant or deny the benefit sought.

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and

any requested evidence, may delay a final decision or result in denial of your Form G-28.

ROUTINE USES: The information you provide on this form may be shared with other Federal, State, local, and foreign

government agencies and authorized organizations following approved routine uses described in the associated published

system of records notices [DHS-USCIS-007 - Benefits Information System and DHS-USCIS-001 - Alien File, Index,

and National File Tracking System of Records, which can be found at The information may also

be made available, as appropriate, for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of

information, unless it displays a currently valid OMB control number. The public reporting burden for this collection of

information is estimated at 20 minutes per response, including the time for reviewing instructions and completing and

submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination

Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140; OMB No. 1615-0105.

Do not mail your completed Form G-28 to this address.

Form G-28 Instructions 02/28/13 N

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