Form I-508f - Request For Waiver Of Rights, Privileges, Exemptions, And Immunities For French Nationals Page 4

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Part 5. Contact Information, Statement, Certification, and Signature of the Person Preparing this
Request, If Other Than the Requestor (continued)
Preparer's Mailing Address
3.
Street Number and Name
Apt.
Ste.
Flr.
Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Fax Number
6.
Preparer's Email Address (if any)
Preparer's Statement
7.
A.
I am not an attorney or accredited representative but have prepared this request on behalf of the requestor and with the
requestor's consent.
B.
I am an attorney or accredited representative and my representation of the requestor in this case
extends
does not extend beyond the preparation of this request.
NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this
request, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, with this request.
Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this request on behalf of, at the request of, and
with the express consent of the requestor. I completed this request based only on responses the requestor provided to me. After
completing the request, I reviewed it and all of the requestor's responses with the requestor, who agreed with every answer on the
request. If the requestor supplied additional information concerning a question on the request, I recorded it on the request.
Preparer's Signature
Preparer's Signature
8.
Date of Signature (mm/dd/yyyy)
Form I-508F 05/26/17 N
Page 4 of 4

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